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DISEASES  OF  THE  HEART: 


DIAGNOSIS  AND  TREATMENT. 


BY 

DAVID  WOOSTER,  M.  D. 

MEMBER  OF  THE  BOTAL  ACADEMY  OF  BiTEDICINE  AND  SURGEEY  OF  TURIN, 

Assistant  Surgeon  in  tlie  "Mexican  War,"  Surgeon  (Major)  in 
the  late  Civil  War,  Author  of  "  Diphtheria  and  Congen- 
ital Asphyxia  "  (1859),  Founder  and  former 
Editor  of  "The  Pacific  Medical  and 
Surgical  Journal,"  etc.,  etc. 


:\ui£  L/e/^ 


SAN       FRANCISCO: 
H.    H.    BANCROFT    AND    COMPANY. 

1867, 


Entered  according  to  Act  of  Congress,  by  David  Wooster,  in  the 
Clerk's  Office  of  the  District  Court  of  the  United  States  for  the  Northern 
District  of  the  State  of  California,  in  the  year  1867. 


Printed  by  Thompson  &  Co., 
No.  536  Market  Street,  opposite  Second, 

SAN    FJBANCISCO. 


TO 

William  Henry  Patterson,  Esq., 

of  San  Francisco,  I  dedicate  this  volume,  as  a  token  of 
admiration  and  long  personal  friendship. 

David  Wooster. 

14  Geary  street,  San  Francisco, 
September,  1867. 


11689? 


PREFACE. 


In  writing  the  following  pages,  I  have  been  scrupulously 
careful  not  to  place  my  own  unsustained  assertions  in  oppo- 
sition to  the  results  of  clinical  demonstrations  or  extreme 
probabilities.  I  have  also  endeavored  to  give  the  anatomy, 
or  topography,  of  the  structures  under  consideration,  with  as 
much  accuracy  as  possible. 

There  are  no  such  obstacles  now,  in  the  way  of  writing 
intelligibly  on  diagnosis  of  diseases  of  the  heart,  as  there  were 
even  twenty-five  years  ago.  If  medicine  has  not  yet  become 
a  science,  it  has,  at  least,  so  far  advanced  as  to  recognize  its 
own  defects,  and  to  be  conscious  of  its  absolute  knowledge. 
Physicians  now  know  where  their  knowledge  ends  and  their 
theories  begin  ;  and  in  this  they  are  far  in  advance  of  their 
forefathers. 

My  aim  has  been  to  limit  myself,  as  closely  as  possible,  to 
known  facts,  and  to  indulge  in  no  idle  speculations,  for  the 
purpose  of  introducing  some  favorite  theory  of  my  own,  in 
order  to  make  myself  seem  original.  I  need  not  tell  my  in 
telligent  readers  that  this  treatise  is  merely  an  abstract ;  but 
it  is  hoped  that  they  will  find  it  what  the  author  designed  it 
to  be,  a  careful  and  conscientious  epitome  of  the  knowledge 
now  possessed  by  the  profession  on  the  subject  of  which  it 
treats.  My  only  claim  to  their  commendation  will  consist 
in  having  placed  .the  knowledge  already  possessed  in  a  more 
accessible  form,  of  having  made  the  facts  we  daily  need  to 
use  more  tangible,  by  stripping  them  of  some  of  their  garni 
ture,  and  grouping  them  in  closer  and  more  obvious  relations 
to  each  other. 


ii  PREFACE. 

I  have  endeavored  to  condense  the  statement  of  facts  into 
a  much  smaller  compass  than  they  appear  in  the  standard 
authors,  without  omitting  anything  necessary  to  a  clear  un- 
derstanding of  the  subject  treated.  In  the  process  of  con- 
densation, I  have  frequently  used  several  successive  words, 
just  as  they  occurred  in  the  authority  consulted,  and  perhaps 
occasionally  a  full  sentence,  without  quotation  marks.  But, 
while  I  make  no  pretence  to  having  written  a  work  original 
in  material,  I  have  endeavored  to  avoid  the  crime  of  plagi- 
arism. 

•  I  have  ventured  to  make  some  suggestions  in  diagnosis, 
not  of  a  radical  kind,  but  merely  as  to  applicability  and  im- 
port of  certain  signs,  and  also  to  indicate  additional  treatment 
in  some  forms  of  heart  disease  to  that  which  authors 
generally  recommend ;  but,  as  I  have  at  the  same  time 
pointed  out  wherein  I  have  ventured  to  differ  with  the  mas- 
ters, the  reader  vrill  not  be  beguiled  into  mistaking  my 
treatment  for  that  of  authors  whom  he  may  with  just  reason 
hold  in  higher  estimation.  I  have  insisted  with  some  perti- 
nacity on  the  reflex  treatment  of  unsoundness  of  the  heart, 
but  for  my  opinions  on  the  value  of  this  kind  of  treatment, 
I  am  indebted  to  Radcliffe,  Brown-Sequard,  and  others  who 
have  investigated  the  more  recondite  departments  of  human 
physiology. 

I  have  had  much  less  to  say  of  treatment  than  of  diagnosis, 
because  in  reality  much  lesr^  is  known  of  the  former  than  of 
the  latter.  We  are  yet  entirely  ignorant  of  the  manner  in 
which,  or  of  the  prime  cause  why  the  heart  becomes  unsound 
by  the  deposition  of  anahjgous  tissues,  in  most  cases,  and 
until  we  have  acquired  this  knowledge,  we  cannot  do  much 
more  than  treat  certain  symptoms,  which  are  common  to 
either  acute  or  chronic  inflammations.  But  thanks  to  our 
almost  exact  knowledge  of  the  beginning  and  process  of 
acute  inflammations,  derived  from  a  multitude   of  clinical 


PREFACE.  iii 

cases,  carefully  observed  in  all  countries,  by  eminent  and 
conscientious  physicians,  we  are  now  able  to  treat  symptoms 
with  a  degree  of  rationality  which  will  accomplish  a  purpose 
predetermined  on  the  part  of  the  physician,  and  which  will 
generally  result  in  success  in  curable  cases,  and  in  the 
alleviation  of  the  most  hopeless. 

Cases  of  heart  disease  are  of  alarming  frequency  in  Cali- 
fornia, yet,  in  the  absence  of  statistics,  it  would  be  improper 
to  say  categorically  that  this  affection  is  excessively  frequent 
here ;  still  I  feel  convinced  that  it  is,  and  were  its  etiology 
within  the  scope  of  this  treatise,  I  think  it  could  be  satisfac- 
torily shown  why  disease  of  the  heart  is  more  likely  to  be 
prevalent  in  newer  than  in  older  civilizations,  and  in  this 
climate  than  in  many  others  ;  and  under  the  special,  moral, 
mental  and  hygienic  influences  which  characterize  us,  than 
under  those  which  predominate  in  other  centres  of  popula- 
tion. For  example  :  the  physical  aspect  of  the  country  and 
metropolis — mountainous  and  hilly — reverse  of  fortune  and 
the  vital  depression  consequent  upon  it ;  family  ties  rudely 
sundered,  and  the  despair  resulting ;  the  insatiable  thirst 
for  riches,  and  the  unusual  energy  employed  in  acquiring 
them,  to  the  deprivation  of  mind  and  body  of  essential  rest  ; 
the  exposure,  night  and  day,  to  which  our  mining  popula- 
tion is  subject ;  the  tunnel  and  deep  drift  work  of  the  quartz 
miner ;  the  excessive  intemperance  in  drink — the  thousand 
disappointments,  and  misfortunes,  and  endless  unrest  to  which 
a  population  anxi6us  to  become  rajjidly  rich,  like  ours,  must 
ever  suffer,  are  so  many  reasons  why  the  heart  should  be- 
come diseased  and  exhausted  under  the  great  labor  of  pro- 
viding for  such  extravagant  use  of  all  the  functions  of  life. 

It  is  on  account  of  my  opportunities  for  observation  during 
the  seventeen  years  I  have  been  practising  medicine  in  Cali- 
fornia, and  the  hope  that  I  might  add  some  little  to  the 
facility  of  diagnosis,  and  the  success  in   the  treatment  of 


iv  PREFACE. 

affections  of  tlie  heart,  and  that  I  might  materially  diminish 
the  labor  of  finding  the  knowledge  that  has  already  been 
published,  that  I  determined  to  make  this  slight  addition  to 
medical  literature. 

This  small  work  has  been  prepared  during  the  intervals  of 
daily  toil,  and  hence  it  lacks  that  unity  of  design  and  unin- 
terrupted sequence  of  subjects  and  sentences  which  are  desira- 
ble in  a  strictly  systematic  treatise ;  but  inasmuch  as  it 
does  not  aspire  to  that  category,  I  trust  it  will  be  con- 
sidered with  some  indulgence  in  this  respect.  Those  who 
desire  a  complete,  systematic  and  exhaustive  treatise,  written 
with  the  most  logical  clearness,  will  find  that  of  Walshe  on 
"  Diseases  of  the  Heart"  unsurpassed  in  any  language. 

I  have  freely  consulted  Walshe,  Hope,  Latham,  Stokes, 
Bennett,  Markham,  Skoda,  Rokitansky,  Radcliffe,  Brown- 
Sequard,  See,  Virchow,  Claude  Bernard,  Flint,  Piorry,  and 
numerous  other  authors  ;  also,  current  medical  literature  of 
standard  authority. 

I  am  under  many  obligations  to  my  friend  Dr.  J.  N.  Brown, 
of  San  Jos6,  one  of  the  most  learned  and  successful  physi- 
cians in  California,  for  valuable  suggestions  and  criticisms 
during  the  compilation  of  this  epitome,  I  am  conscious  of 
many  imperfections  in  it,  both  in  -diction  and  manner  of 
arrangement.  With  many  misgivings,  I  offer  it  to  the  pro- 
fession, asking  for  it  merely  the  indulgence  which  a  con 
scientious  author  has  a  reasonable  right  to  expect  of  a 
conscientious  reader. 

DAVID  WOOSTER. 

San  Francisco,  September,  1867. 


CONTENTS. 


Dedication.  page. 

Preface. 

Contents. 

Chapter  I. 

Introduction.    Causes  of  Discrepancies  of  Opinion  in 

Cases  where  Exactness  is  possible 5 

Chapter  II. 
Anatomical  and  Physiological  Facts  concerning  the 
Location  of  Valves,  and  Origin  of  Heart's  Sounds.    10 
Chapter  III. 

Diagnostic  Signs  of  Endocarditis  Pericarditis,  and 
Insufficiency   of  the    Mitral  Valve.     Cases  and 

Treatment 19 

Chapter  IV. 

Disease  of  the  Semilunar  Valves  of  the  Aorta.  Direct 
and  Regurgitant  Murmurs — Differential  Diagnosis 
of.  Treatment  of  Disease  of  the  Aortic  Valves, 
and  its  Complications 48 

Chapter  V. 
Valves  of  the  Pulmonary  Artery.     Constriction  of  the 
Mitral  Orifice.   Constriction  of  the  Right  Auriculo- 

Ventricular  Orifice 86 

Chapter  VI. 
Inorganic  Murmurs — How  Distinguishable  from  Or- 
ganic.   Diastolic  Inorganic  Murmur 96 

Chapter  Vn. 
Pericarditis  and  Endocarditis.  Endo-pericarditis.  Car- 
ditis   103. 


11  CONTENTS. 

Chapter  VIII.  page. 

Hypertrophy.     Dilatation 134 

Chapter  IX. 
Fatty  Metamorphosis  or  Degeneration,  or  Fatty  Sub- 
stitution  of  the  Heart.     Rupture  of  the  Heart. 

Cases 150 

Chapter  X. 
Thoracic    Aneurisms  :     Diagnosis     and     Treatment. 
Cyanosis  and  Atelectasis.      Appreciation  of  the 

true  cause  of  Cyanosis 172 

Chapter  XI. 

General  Rules  for  Diagnosis  and  Treatment  of  Dis- 

eases^of  the  Heart 179 

Chapter  XII. 
General  Reflections  as  to  Prognosis  in  Organic  Dis- 
eases of  the  Heart 187 

Appendix  A. — First  Sound  of  the  Heart 201 

B.— Intermittent  Pulse 201 

C. — Causes  of  Dropsy 203 

D. — ^Mode    of    Death  in   Mitral    Disease. 

Cause  of  Pain 204 

E.— Pericardial  Effusion 205 

F. — Absence  of  First  Sound  in  Softening 

and  Pericardial  Effusion ...  206 

G. — Saline  Evacuants 206 

H. — Embolism,  how  developed.    Cause  of 

Coagulation  of  the  Blood 207 

"  I. — Tables  of  the  Thickness  of  Ventricles. 

Order  of  Valvular  Diseases 209 

Errata. 

Diagram,  exhibiting  the  relationship  of  the  heart  and 
great  vessels  to  the  limgs,  (in  moderate  inspira- 
tion,) and  to  the  regions  of  the  chest.. 210 

Index. 


Y-  TH£ 


''^ 


CHAPTER  I. 

Introduction.     Causes  of   Discrepancies  op  OprNioN 
IN  Cases  where  Exactness  is  Possible. 

1.  Many  works  have  been  written  on  diseases 
of  the  heart,  and  its  affections  have  been  de- 
scribed and  treatment  recommended  in  all  stand- 
a.rd  works  on  the  practice  of  medicine  ;  but 
it  has  occurred  to  me  that  the  matter  might 
be  much  condensed,  without  detriment  to  scien- 
tific exactness  and  with  great  benefit  to  actual 
sufferers^ 

2.  Physicians  well  know  in  their  own  minds 
that  a  very  small  proportion  of  the  practitioners 
of  medicine  are  able  to  diagnose  an  affection  of 
the  heart  with  even  tolerable  exactness  ;  not 
only  are  they  unable  to  say  what  valve  is  affec- 
ted, but  they  do  not  distinguish  the  side  of  the 
heart ;  still  worse,  many  who  listen  cannot  dis- 
tinguish normal  from  abnormal  sounds,  the  beat 
of  a  healthy  from  the  throb  of  a  diseased  heart. 

This  inability  of  discriminating  sounds,  with 
some  is  a  natural  defect,  a  physiological  defi- 


h  DISEASES   OF   THE  HEART  ! 

ciency  in  the  ability  to  compare  small  discrep- 
ancies. But  the  inability  generally  is  less  seri- 
ous ;  it  is  a  lack  of  the  acquirement  and  recol- 
lection of  facts  which  may  be  acquired  and  re- 
membered by  most  persons  of  intelligence. 
These  facts  can  be  acquired  only  by  diligent 
study,  and  numerous  examples,  carefully  and 
rigidly  observed.  For  example  :  a  person  who 
has  acquired  the  elements  of  Latin,  when  he 
attempts  to  translate  a  sentence  of  Latin  into 
English,  if  he  is  really  acquainted  with  the 
structure  of  the  original,  is  altogether  sure 
Avhen  he  has  rendered  its  true  meaning.  If  he 
have  less  or  more  than  the  true  meaning,  he 
will  be  conscious  of  the  deficiency  or  redundancy; 
or  if  different  from  the  true  he  will  know 
wherein  the  difference  consists.  But  one  who 
lacks  this  knowledge  of  the  principles  of  the 
original  language,  will  never  be  quite  sure  of 
his  translation  ;  there  will  always  remain  some 
doubt  in  his  own  mind  about  the  exactness  of 
his  rendering.  No 'amount  of  labor,  without  a 
knowledge  of  the  fundamental  facts,  will  be  of 
any  avail.  So  he  who  practices  physical  diag- 
nosis, must  first  of  all,  be  well  grounded  in  the 
meaning  of  natural   sounds   and   signs,   and  in 


THEIR  DIAGNOSIS  AND   TREATMENT.  7 

tlieir  topography  on  and  in  the  body.  Of  what 
use  is  it  to  recognize  crepitus  if  we  do  not  know 
what  crepitus  indicates.  Of  what  use  to  recog- 
nize murmurs  if  we  know  not  from  whence  they 
proceed,  their  cause  and  significance?  Two 
physicians,  with  diplomas  from  respectable  med- 
ical colleges,  will  examine  a  chest  the  same  day. 
One  will  say  there  are  softened  tubercles  in  a 
lobe  of  the  right  lung,  but  that  the  left  lung  is 
natural ;  the  other  will  say  th*^  right  lung  is 
not  affected  at  all,  but  he  finds  one  or  more 
cavities  in  the  left  lung.  Now,  if  the  patient 
goes  on  to  other  physcians,  perhaps  the  next 
will  tell  him  he  has  a  bronchitis  or  a  catarrh  ; 
the  third  will  tell  him  his  "lungs  are  more  than 
half  gone,'^  while  a  fourth  will  tell  him  categor- 
ically, his  lungs  are  perfectly  sounds  but  that  he 
has  disease  of  the  heart. 

All  physicians  recognize  this  gamut  of  opin- 
ions on  the  same  case,  examined  the  same  week. 
Whence  do  such  discrepancies  arise  ?  They  do 
not  always  arise  from  inability  on  the  part  of 
the  examiner,  less  frequently  from  lack  of  frank- 
ness. Yet  the  result  is  the  same  on  the  mind 
of  the  patient  and  his  friends  and  of  the  com- 
munity, as  if  the  disagreement  in  opinion  were 


8  DISEASES   OF  THE  HEART  : 

the  result  of  ignorance;  In  some  cases,  doubt- 
less in  most,  when  the  discrepancy  is  so  irrecon* 
cilable,  the  doctors  have  examined  superficially^ 
and  the  ear  of  each  has  been  placed  over  a  dif- 
ferent portion  of  lung,  and  the  examination  has 
not  been  minute  and  exhaustive.  One  listened, 
perhaps,  at  a  lower  lobe,  the  other  at  an  upper^ 
one  placed  his  ear  just  below  a  clavicle,  the 
other  placed  his  just  behind  a  scapula  ;  one 
listened  carefullj^  on  one  and  carelessly  on  the 
other  side,  while  the  other  observed  closely 
both  sides  of  the  chest ;  and  finally  one  knew 
not  the  meaning  of  the  sounds  elicited,  or 
heard  with  the  ear,  while  the  other  appreciated 
their  precise  significance. 

But  until  professional  opinions  shall  more 
nearly  harmonize  on  matters  of  simple. fact  in 
physical  diagnosis,  the  people,  will  not  have 
implicit  confidence  in  the  opinion  of  any  one  of 
us,  however  excellent. 

If  a  patient  with  aortic  insufficiency,  or  tuber- 
cular cavity  under  the  right  clavicle,  should  be 
examined  by  twenty  physicians  in  succession, 
and  the  whole  twenty  should  verify  the  insuffi- 
ciency in  the  same  place,  or  the  cavity  in  the 
same   portion  of  lung,  and  if  similar  harmony 


THEIR   DIAGNOSIS   AND   TREATMENT.  9 

of  opinion  on  matters  within  the  reach  of  exact 
diagnosis,  should  prevail  even  with  twenty  phy- 
sicians in  one  large  city,  where  there  are  five 
hundred  doctors,  as  there  are  in  San  Francisco, 
I  say,  if  twenty  would  agree-  on  ascertainable 
facts,  the  profession  would  very  soon  possess  the 
entire  confidence  of  the  people.  The  fault  is  in 
our  own  carelessness  or  inability  ;  and  whether 
we  are  careless  or  ignorant,  the  result  is*  much 
the  same.  * 

4.  I  purpose  in  the  following  pages  to  give 
a  brief  summary  of  what  is  known  about  diag- 
nosis and  treatment  of  diseases  of  the  hearty  and 
to  show  how  simple  it  is  for  all  educated  physi- 
cians to  say  positively  what  portion  of  the  heart 
is  affected  in  most  cases,  and  to  show  in  the  few 
cases  in-which  positive  diagnosis  is  unattainable 
that  an  extremely  probable  diagnosis  may  be 
given,  sufficiently  exact  at  least  to  form  the 
basis  of  rational  treatment. 


10  DISEASES   OF   THE   HEABT  : 

CHAPTER  II. 

anatomicaii     and     physiological    facts    coxcerking 
Location  of  Valtes,  and  Origin  of  Heart's  Sounds. 

1.  No  two  hearts  are  the  same  size.  No  two 
persons'  hearts  beat  precisely  aUke,  or  so  nearly- 
alike,  but  that  a  practiced  ear  would  distinguish 
the  deference  in  the  dark.  Yet  the  healthy 
beat  of  the  heart  is  so  different  from  the  un- 
healthy, that  the  practiced  listener  would  be 
able  to  say  without  seeing  the  patient's  face, 
whether  the  heart  was  health^^  or  affected. 

2.  The  heart  has  a  more  or  less  conical  form, 
and  is  suspended  obliquely  in  the  chest ;  its  base 
corresponds  with  the  median  line  of  the  breast 
bone,  but  is  directed  upwards  and  backwards 
towards  the  backbone,  while  its  apex  is  directed 
downwards  and  forwards  and  to  the  left,  so  that 
when  the  heart  contracts  the  apex  is  felt  and 
seen  to  strike  the  chest  between  the  fifth  and 
sixth  ribs,  below  and  a  little  to  the  right  of  the 
left  nipple,  ivlien  the  person  stands  erect.  If  he 
lean  forward  the  beat  strikes  not  only  the  fifth 
intercostal  space,  but  the  fifth  rib  and  a  little 
farther  towards  the  breastbone.     If  he  lie  down 


THEIE   DIAGNOSIS   AND   TREATMENT.  11 

on  his  back,  the  apex  beat  is  imperceptible  any- 
where. If  he  turn  on  his  left  side  he  renders 
it  more  perceptible  than  in  the  erect  position, 
but  in  a  larger  space  more  towards  the  nipple 
than  the  sternum.  And,  finally,  if  he  turn  on 
his  right  side,  the  heart's  impulse  against  the 
chest  is  scarcely,  or  not  at  all  perceptible. 

These  are  obvious  facts,  but  well  worth  re- 
membering. 

3.  Aside  from  all  nice  distinctions,  the  ear 
recognizes  hvo  natural  sounds  of  the  heart. 
These  are  known  as  the  first  and  second  sounds 
of  the  heart. 

4.  The  first  sound  is  heard  most  distinctly 
over  the  anterior  surface  of  the  heart,  on 
the  fifth  costal  cartilage,  left  side,  at  a  point 
midway  between  its  junction  with  the  sternum 
and  its  junction  with  the  rib.  *'  It  is  long,  dull, 
and  smothered  in  tone,  and  occupies  one-half 
the  duration  of  a  single  beat.''  It  corresponds 
in  time  with  the  impulse  of  the  heart  in  the 
precordial  region. 

5.  The  precordial  region  is  certainly  found  by 
describing  a  circle,  with  a  radius  of  one  inch, 
from  a  point  in  the  fifth  costal  cartilage,  left 


12  DISEASES   OF   THE   HEART: 

side,  midway  between  its  junction  with  the  rib 
and  its  junction  with  the  sternum.  ''  In  this  case 
we  suppose  a  well  formed  chest."     (Latham.) 

6.  The  second  sound  is  heard  most  distinctly 
in  the  situation  of  the  aortic  and  pulmonic 
valves  ;  it  follows  immediately  upon  the  first 
sound,  with  scarcely  an  appreciable  interval. 
It  is  short,  sharp,  and  distinct  in  tone,  and 
occupies  one  quarter  of  the  whole  of  a  pulsation. 

7.  "  A  line  drawn  through  the  inferior  margins 
of  the  third  rib,  across  the  sternum,  passes 
through  the  pulmonic  valves  a  little  to  the  left 
of  the  mesial  line,  and  those  of  the  aortia  lie 
behind  them,  but  about  half  an  inch  lower 
down."     (Hope.) 

"  The  aortic  and  pulmonary  valves  are  situa- 
ted under  the  sternum,  at  the  level  of  the  third 
costal  cartilage."     (Dalton.) 

8.  The  first  sound  of  the  heart  is  caused  by 
the  closure  of  the  auriculo-ventricular  valves — 
mitral  and  tricuspid  valves — valves  between  the 
left  ventricle  and  auricle,  mitral ;  valves  be- 
tween the  right  ventricle  and  auricle  tricuspid. 

9.  *'  A  horizontal  line  drawn  through  (''along?" 
Latham)  the  under  edge  of  the  sterno-costal 


THEIR   DIAGNOSIS   AND    TREATMENT.  13 

articulations  of  the  fourth  ribs  will  cut  across 
nearly  the  middle  of  the  length  of  the  mitral 
valve,  when  drawn  outwards  and  downwards  by 
its  tendinous  cords  and  fleshy  columns,  and 
pass  about  two  or  three  lines  above  that  por- 
tion of  the  tricuspid  which  most  nearly  ap- 
proaches it,  the  latter  valve  lying  undeuneath 
the  sternum,  and  the  former  immediately  to 
its  left.'^     (Joy.) 

10.  The  second  sound  is  undoubtedly  caused 
by  the  closure  of  the  semi-lunar  valves  (aortic 
and  pulmonic).  The  first  and  second  sounds 
occur  in  the  same  order  as  the  closure  of  the 
two  sets  of  valves  :  1st,  the  two  auriculo-ventri- 
cular   valves — mitral  and   tricuspid,  shut   back, 

first  sound  ;  directly  upon  this  the  two  sets  of 
semi-lunar  valves,  aortic  and  pulmonic,  shut 
back  ;  second  sound. 

11.  The  sounds  of  the  heart,  their  cause,  and 
the  location  from  whence  they  proceed  being 
granted,  and  their  quality  being  ascertained 
from  the  examination  of  persons  in  health,  the 
inference  is  clear  that  any  marked  variation 
from  this  standard  will  be  abnormal,  and  a  sign, 
considered  by  itself,  of  disease  of  the  particular 


14  DISEASES   OF   THE   HEART: 

Structures    from   which    the    marked   variation 
proceeds. 

12.  Persons  die  of  .''heart  disease"  almost 
daily,  but  whether  of  disease  of  the  inside  or 
outside  of  the  heart,  whether  of  the  valves  or 
of  the  substance  of  the  heart,  the  record  scarcely 
ever  ishows.  A  distinguished  London  physi- 
cian said,  after  thirty  years  of  practice,  that 
two-thirds  of  his  professional  life  passed  before  he 
could  discriminate  between  an  inflammation  of 
the  cavities  of  the  heart  and  of  its  outside  j  before 
*  he  could  tell  an  endocardial  from  an  exocardial 
murmur.  No  physician  in  the  world  could  make 
this  distinction  before  1826.  And  yet  it  is  of 
great  importance  to  know  there  is  a  distinction,, 
and  to  know  what  the  distinction  suggests  of 
the  health  and  probabilities  of  life  to  the  pa- 
tient. 

«.  We  will  say  then  categorically,  that  an 
educated  ear  can,  in  almost  every,  if  not  every 
case,  distinguish  an  exocardial  from  an  endocar- 
dial murmur  ;  and  hence  a  pericardial  from  an 
endocardial  affection. 

&.  Perhaps  in  nine-tenths  of  the  cases  in  which 
the  heart  is  diseased,  its  inside  rather  than  out- 


THEIR   DIAGNOSIS   AND   TREATMENT.  15 

side  is  aflfeeted.  Affections  of  the  outside  of  the 
heart,  or  of  the  pericardium  are  comparatively 
rare. 

c.  Men  are  more  liable  to  heart  disease  than 
women  ;  adults  are  more  liable  than  youths 
and  children;  residents  of  cities  are  more  liable 
than  residents  of  the  country  ;  dissipated  peo- 
ple are  more  liable  than  those  of  regular  habits. 
The  rich  are  more  liable  than  the  poor. 

d.  Courtezans  rarely  have  disease  of  the 
heart  I 

6.  Excessive  indulgence  of  the  erotic  passion, 
is,  on  the  contrary,  in  men  a  great  aid  to  the 
development  of  endocardial  disease,  and  also 
of  acute  rheumatism,  which  is  a  conspicuous 
and  very  common  forerunner  of  pericarditis. 

/.  It  is  obvious  there  is  no  opposition  in 
propositions  d  and  e,  but  rather  correlation. 
There  is  all  the  difference  conceivable  in  the 
physiological  effect  of  erotism  in  man  and 
woman. 

13.  It  may  be  said  in  general  terms  that 
every  acute  disease  of  the  heart  is  an  inflamma- 
tion, and  if  rationally  treated,  does  not  necessa- 
rily cause  death. 

But  the  world  is  much  more  concerned  with 


16  DISEASES    OF   THE   HEART'. 

those  diseases  of  the  heart  which  are  not  inflam- 
mation, and  that  do  not  result  from  any  direct 
injury,  or  any  sudden  or  acute  disease. 

Certain  growths  in  the  body  are  called  hetere- 
logous  as  tubercle,  carcinoma,  cepbaloma,  etc., 
and  the  heart  even  is  not  exempt  from  hetero- 
logus  growths  of  this  nature  ;  but  they  are  ex- 
ceedingly rare,  so  much  so  as  to  be  almost  be- 
yond the  field  of  research. 

Bat  permanent  disease  of  the  heart  is  derived 
from  the  deposition  in  some  portion  of  it,  of 
analogous  tissues  ;  that  is  analogous  to  healthy 
tissues.  The  cartilage  and  bone  deposited  in 
the  heart  and  arteries  is  analogous  to  cartilage 
and  bone  in  the  joints,  though  not  exactly  like, 
either  chemically  or  physiologically.  It  is  dis- 
ease of  the  heart  caused  by  these  deposits,  and 
that  caused  by  the  deposition  of  fat  in  the 
substance  of  the  heart  and  also  that  caused  by 
atheromatous  deposits,  either  alone  or  in  com- 
pany' with  cartilage  and  bone,  with  which  we 
are  most  concerned. 

14.  With  the  pathological  history  of  these 
diseases  I  shall  have  but  little  to  do  in  this 
monogram.     Their  beginning,  progress  and  cul- 


THEIR   DIAGNOSIS   AND   TREATMENT.  17 

mlnation^  and  the  causes  of  their  beginning, 
duiJ-ation  and  termination,  are  pretty  well  known 
to  observers,  but  just  why  cartilage,  and  bone, 
and  fat,  one  or  all,  should  be  deposited  slowly, 
so  slowly  as  not  to  attract  the  attention  of  the 
victim,  in  the  heart  of  a  habitual  drinker  more 
than  in  the  heart  of  an  excessive  feeder,  we 
cannot  explain;  but  the  same  thing  is  done  in 
old  age  even  in  those  who  have  lived  the  most 
regular  lives.  Therefore,  for  this  reason  alone 
it  is  probable,  and  we  know  by  observation  that 
it  is  certain,  that  excess  in  drinking  induces 
premature  t)ld  age,  and  the  deposit  in  the  heart 
of  organic  substances,  analogous  to  the  healthy 
tissues,  but  of  a  lower  formative  grade,  composed 
of  dwarfed  or  defective  form  elements,  just  as 
we  observe  in  old  age. 

15.  This  slow,  permanent  unsoundness  of  the 
heart  is  caused  by  something  equivalent  to  old 
age,  and  the  result  will  be  the  same,  death, 
unless  the  habit  is  changed  and  reparation  made 
for#loss  sustained.  Hotvever  much  we  do  the 
result  will  alivays  fall  short  of  complete  resfora- 
iion  of  the  heart  to  as  sound  a  condition  as  it 
tvas  before  the  deposit  of  the  analogous  tissue.*]. 

16.  We  are  accustomed   to   say   that  heart 


18  DISEASES   OF   THE   HEART  : 

disease  comes  of  itself.  If  one  has  an  inflamed 
eye,  we  say  the  eye  has  been  recently  hurt,  or 
exposed  to  a  cold  wind  or  some  contagion  ;  if 
one  has  a  fever,  we  say  he  has  been  exposed  to 
its  cause  recently.  We  recognize  these  causes, 
and  always  refer  to  them  for  the  solution  of  the 
phenomena  of  acute  affections  }  not  so  with 
chronic  diseases,  we  are  apt  to  say  they  come  of 
themselves  ;  and  yet  they  have  causes  as  defi- 
nite and  appreciable  as  an  intermittent  fever  or 
a  pneumonia  ;  but  they  are  so  long  in  acting 
that  we  keep  no  record  of  them,  and  do  not 
seek   them   until   the     disease   take^  form   and 

place. 
\ 
We   do  not  know   why    this   premature   old 

age  seizes  on  the  heart  rather  than  the  lungs  or 
liver  ;  why  it  does  not  at  the  same  time  cause 
wrinkles,  and  parchment  coloration  of  the  skin. 
These  negative  inquiries  are  unprofitable,  and 
if  answered  would  not  elucidate  the  unsolved 
problem  ;  why  are  analogous  growths  deposited 
in  the  heart  at  all  ?  They  are  deposited  be- 
cause one  dissipates.  But  why  does  dissipation 
cause  them  ?  Because  it  induces  old  age?  But 
why  does  old  age  cause  these  deposits?  Because 
nutrition  is  defective,  and  hence  the  form  ele- 


THEIR   DIAGNOSIS   AND   TREATMENT.  19 

meats  are  dwarfed  and  imperfect.  But  why 
is  nutrition  defective  in  old  age  ?  Here  the 
oracle  returns  no  longer  any  satisfoctor}^  an- 
swer, and  hence  the  first  question  remains  un- 
answered and  Unanswerable  ;  that  is,  we  do 
not,  and  probably  never  can  know  wljy  anala- 
gous  growths  are  deposited  in  the  heart  at  all. 


CHAPTER  m. 

BiAG^^osTic  Signs  of  Ekdocarditis  Pericarditis,  and  In- 

SUFFICIENCY   OF   THE   MlTRAL  VaLVE.     CaSES.^     TREAT- 
MENT OF  Mitral  Insufficiency. 

1.  We  haye  seen  that  the  first  sound  of  the 
heart  is  caused  by  the  closure  of  the  auriculo- 
ventricular  valves— mitral  and  tricuspid.  '^ 

2.  That  the  second  sound  is  caused  by  the 
closure  of  the  semilunar  valves  of  the  aorta  and 
pulmonary  artery  shutting  back  at  the  same  in- 
stant. 

3.  Endocardial  murmurs  are  distinguishable 
from  exocardial/Hc^i07?.s. 

4.  The  ear  cannot  mistake  a  murmur  for  a  fric- 
tion, nor  the  contrary — hence  when  there  is  a 
persistent  murmur  the  affection  is  surely  within 
the  heart. 


*  I  do  not  venture  to  say  that  there  is  no  other  element  in 
the  causation  of  first  sound,  but  the  closure  of  auriculo- 
ventricular  valves  is  the  only  cause  of  any  practical  import- 
ance. 


20  i)tSEASES   OP   THE  HEART  ! 

5.  When  there  is  a  friction  sound,  persistent  or 
not,  there  is  pericarditis  acute  ot  chroliic  ;  and 
the  disease  is  outside  the  heart. 

6.  Now,  if  murmurs  proceed  from  diseased 
valves,  the  murmur  should,  other  things  equal, 
be  heard  loudest  when  the  ear  is  nearest  the 
affected  valve. 

If  the  mitral  valve  is  affected  the  murmur  will 
coincide  with  a  part  or  all  of  the  first  sound  ;  and 
lie  heard  most  distinctly,  either  at  the  apex  of  the 
heart  that  is  where  the  heart  is  seen  and  felt  to 
strike  the  chest  below  the  left  nippje,  or,  a  little 
above  the  left  nipple,  to  the  left  of  the  sternum, 
between  the  fourth  and  fifth  ribs,  directly  over 
the  mitral  valve.  If  the  disease  is  of  the  mitral 
valve,  the  sound  will  be  heard  distinctly  at  the 
apex  of  the  heart,  and  perhaps  for  some  dis- 
tance below  it  in  the  same  right  line  ;  but  if 
the  aortic  valves  are  affected,  the  murmur  will 
be  heard  loudest  just  about  where  the  mitral 
murmur  was  heard  loudest;  but  in  place  of  being 
heard  more  distinctly  in  the  direction  of  the 
apex,  it  will  be  heard"  more  distinctly  in  the 
direction  of  the  aorta,  that  is  over  the  sternum, . 
opposite  the  second  rib.  (The  aorta  ascends 
behind  the  sternum,  obliquely  upwards  and  for- 


THEIR    DIAGNOSIS   AND   TREATMENT.  21 

wards  towards  the  right  side  until  it  reaches 
the  upper  border  of  the  second  costal  cartihige.) 
Whether  the  murmur  proceed  from  the  mitral 
valve  or  the  aortic  valves,  the  murmur  will  at- 
tend the  systole  of  the  heart ;  that  is,  it  will 
coincide  with  the  first  sound.  Whether  the 
murmur  proceed  from  the  aortic  valves  or  the 
mitral  valve  in  nine  cases  out  of  ten  it  will  be 
heard  loudest  in  the  precordial  region,  with 
the  ear  or  stethoscope  placed  over  the  costal 
cartilage  of  the  fourth  rib.  By  listening  over 
the  precordial  .region  only,  no  man  can  say 
which  valve* is  diseased,  because  the  stethoscope 
will  cover  all  the  valves  if  it  is  an  inch  and  a 
half  in  diameter  ;  and  most  physicians  will  con- 
fess that  it  would  be  impossible  to  say  from 
which  portion  of  the  circle  included  in  the 
mouth  of  the  stethoscope  the  murmur  proceeded 
in  a  given  case,  but  if  on  moving  the  stetho- 
scope towards  the  apex  of  the  heart,  the  mur- 
mur should  be  heard  louder  than  it  would  be  if 
moved  up  the  arch  of  the  aorta,  or  in  the  di- 
rection of  the  pulmonary  artery,  the  diseased 
valve  would  almost  certainly  be  the  mitral,  if 
the  murmur  coincided  with  the  hearts  systole. 
In  this  case  the  murmur  would  result  from  the 


22  DISEASES   OF   THE   HEART  ! 

blood  being  repelled  backwards  from  the  left 
ventricle  into  the  left  auricle,  through  the  im- 
perfect mitral  valve.  It  will  be  borne  in  mind 
that  in  health  of  the  heart  the  contraction  of  the 
left  ventricle  impels  the  blood  forwards  through 
the  aorta.  Now  the  aorta  is  composed  of 
powerful  elastic  tissues,  and  hence  it  reacts  with 
violence  on  the  current  forced  through  it  by 
the  ventricular  systole,  and  it  is  obvious  that 
when  the  aortic  valves  are  open,  as  they  are 
during  the  ventricular  systole,  that  if  the  mi- 
tral valve  were  open  also,  there  would  be 
nothing  to  prevent  the  aortic  resistence,  to- 
gether with  the  contraction  of  the  ventricle 
from  repelling  the  blood  through  the  mitral 
orifice  ;  and  it  is  also  obvious  that  this  repul- 
sion would  be  synchronous  with  the  ventricular 
systole,  hence  the  resultant  murmur  would  be 
synchronous  with  the  same  systole,  and  would  be 
}ieard  best,  not  in  the  direction  of  the  aorta, 
but  of  the  axis  of  the  ventricle,  that  is  in  the 
direction  of  *the  apex  of  the  heart,  which  is  the 
apex  of  the  left  ventricle. 

And  by  the  same  reasoning  it  can  be  shown, 
that  if  the  murmur  proceeds  from  the  aortic 
valves,  roughened  with  analogous  growths,  but 


THEIR    DIAGNOSIS    AND   TREATMENT.  23 

not  SO  impaired  as  to  prevent  them  from  closing, 
that  the  murmur  will  be  synchronous  with  the 
first  sound,  and  heard  louder  in  the  direction  of 
the  aorta,  that  is  of  the  onward  current  of  the 
blood,  than  in  the  opposite  direction,  that  is, 
towards  the  apex. 

But  again.  If  the  mitral  \'alve  is  sound,  and 
a  murmur  be  heard  synchronous  with  the  second 
sound,  louder  in  the  direction  of  the  apex  than 
in  the  direction  of  the  aorta,  or  if  it  be  about 
equal  in  both  directions,  there  will  be  imper- 
fect closure — insufficiency  of  the  aortic  valves 
and  the  murmur  is  not  direct,  but  regurgitant, 
proceeding  from  the  resilience  of  the  aorta,  re- 
pelling a  portion  of  the  current  back  through 
the  aortic  valves  into  the  ventricle  from  whence 
it  issued  ;  but  as  this  regurgitation  is  not  abso- 
lutely synchronous  with  the  forward  current 
of  arterial  blood  in  the  aorta,  it  would  be  ex- 
pected that  the  murmur  of  regurgitation  would 
be  carried  downwards  rather  thaij  along  the 
aorta,  because  the  course  of  the  blood  at  the 
moment  of  the  development  of  the  murmur  is 
downwards  into  the  left  ventricle,  in  which  di- 
rection the  murmur  should  be  propagated.  But 
this  is  too  nice  a  distinction  to  be  always  made 


24  DISEASES    OF   THE   HEART  : 

out  definitely  ;  for  at  times  the  murmur  is  so 
loud  as  to  be  heard  distinctly  in  all  directions 
from  its  origin,  and  in  a  radius  of  tvvo  inches 
no  difference  in  pitch  may  be  appreciable  ;  but 
if  the  ear  recedes  some  distance,  it  will  always 
be  found  that  in  regurgitant  aortic  murniur  the 
sound  is  propagated  downwards,  and  is  coinci- 
dent with  the  second  sound,  while  in  merely 
roughened,  but  not  insufficient,  valves,  the  mur- 
mur is  coincident  with  the  first  sound  and  is 
propagated  upwards. 

Diagnosis  of  Organic  Disease  of  the  Heart. 
1. — First,  it  is  premised  that  the  auscultator  or 
physician  is  aware  of  the  following  summary  of 
facts,  Tiamely :  that  there  are  two  sounds — a 
first  and  second ;  the  first  longer  and  less  ac- 
cented than  the  second ;  the  first  propagated 
downwards,  in  the  direction  of  the  heart  ;  the 
second^  upwards  in  the  direction  of  the  ascend- 
ing aorta  ;  the  first  coincident  with  the  pulse, 
t\\Q  second  a,moment  subsequent  to  the  pulse. 

^\iQ  first  sonnd  is  caused  by  the  closure  of  the 
auricTilo- ventricular  valves — tricuspid  right  side, 
mitral,  left  side  of  heart.  (All  the  valves  are 
situated  under  a  little  circle  not  exceeding  an 
inch  and  three-quarters  in  diameter,  w^hich  may 


THEIR   DIAGNOSIS   AND   TREATMENT.   '         25 

be  described  on  the  skin  over  the  base  of  the 
heart.) 

2.  The  second  sound  is  caused  by  the  closure 
of  the  semilunar  valves  of  the  aorta  and  of  the 
pulmonary  artery  ;  the  valves  of  these  two  ves- 
sels close  at  the  same  instant,  and  hence,  though 
each  emit  a  sound  in  closing,  the  ear  of  the 
listener  at  the  precordia  appreciates  but  one 
sound.  Now,  if  the  two  sounds  are  normal  ii: 
pitch,  and  tone,  and  accent,  and  if  the  impulse 
of  the  heart  is  not  excessively  strong,  nor  re- 
markably weak,  if  no  friction  sound,  or  bellows 
murmur  is  heard,  we  say  the  heart  is  sound. 
But  if  a  friction  sound  is  heard  over  the  heart, 
proceeding  from  the  heartj  there  is  organic  dis- 
ease of  its  outside. 

If  a  bellows  murmur,  or  rasping  murmur,  is 
heard  over  the  heart  proceeding  from  the  heart, 
and  the  patient  is  not  pale  or  anaemic,  and  if  the 
murmur  is  persistent,  there  is  organic  disease  of 
the  inside  of  the  heart. 

a.  A  friction  sound  indicates  pericarditis. 

h,  A  blowing  sound — murmur — indicates  either 
acute  or  chronic  disease  of  some  portion  of  the 
heart's  cavities. 

c.  A  friction  sound  and  a  murmur  at  the  same 


26  DISEASES   OF   THE   HEART  : 

time^  indicate  that  endocardial  and  exocardial  disease 
cO'txist. 

y     d.   We  nether  can  be  sure,  of  pericarditis  until  we 
hear  the  friction  murmur. 

e.  We  never  can  be  sure  of  endocarditis  until  we 
hear  the  blowing  murmur. 

3.  Latham  says,  from  simply  listening  to  a 
murmur  and  asking  no  questions,  we  are  not  able 
to  tell  what  it  means.  In  one  who  a  few  days 
since,  while  in  perfect  health,  was  seized  with 
fever,  it  means  one  thing  ;  in  one  out  of  health 
for  some  time,  with  difficult  breathing  and  palpi- 
tation, it  means  another  ;  in  one  deformed  from 
birth,  another  ;  and  in  the  pale  chlorotic  girl, 
another.  Yet  it  is  the  same  kind  of  murmur,  the 
murmur  simulating  the  sound  of  bellows,  in  all ; 
and  being  the  same,  it  cannot  entirely  explain 
itself — it  cannot  be  its  own  interpreter.  It  re- 
quires aid  from  concomitant  circumstances  to 
decide  its  meaning  in  each  particular  case.  The 
aid  it  needs  is  often  very  little  ;  but  that  little 
it  must  have,  and  then  it  tells  its  story  clearly 
and  explicitly. 

Case  1st.  Miss  A.  D.,  unmarried,  aged  twenty, 
pale  and  short-breathed,  cold  hands  and  feet, 
occasional  flush  on  one  cheek,  sometimes  a  short 
dry  cough,  often  dizziness,  headache,  constipa- 


THEIR   DIAGNOSIS   ANI>-.XREATMENT.  27 

tion,  palpitation,  says  she  lias  been  told  by  Dr. 

she  has  "  heart  disease^'  and  is  incurable. 

On  listening  at  precordia,  hear  bellows  murmur, 
with  first  sound  loudest  in  direction  of  aorta  y 
this  murmur  is  persistent  for  a  week,  pulse  96, 
feeble,  accented  ;  heart  sounds  distinct  and  snap- 
pish, that  is,  unusually  definite ;  eye-lids  at  times 
"  pufiy.^^  She  was  assured  she  was  anemic,  and 
had  no  heart  disease,  and  was  curable. 

Treatment. — To  retire  at  9  o'clock,  to  keep  her 
feet  dry,  to  eat  beef-steaks  and  mutton-chops,  and 
take  three  raw  eggs  daily,  to  drink  cofiee  or 
chocolate,  to  work  but  little,  to  take  passive  ex- 
ercise in  the  open  air — (ride  in  cars  or  carriages). 

The  only  medicine  ordered,  if  medicine  it 
could  be  called,  was  equal  parts  of  cod  liver  oil, 
whisky  and  simple  syrup  in  table-spoonful  doses 
three  times  a  day.  Result :  in  two  months  the 
bellows  murmur  could  be  developed  only  after 
violent  exercise,  such  as  swinging  dumb-bells.  At 
the  expiration  of  four  months,  both  paleness,  and 
murmur,  and  palpitation  had  disappeared.  I 
should  mention  she  had  used  vaginal  abluents  of 
a  solution  of  tannic  acid  for  leucorrhoea,  which 
was  thus  arrested. 

This  was  not  a  case  of  organic  heart  disease, 
proved  by  the  crucial  test  of  complete  recovery. 


28  DISEASES   OF    THE    HEART  : 

Case  2d.  Mrs.  B.,  has  been  under  my  care 
eleven  years,  during  which  time  slie  has  had  no 
acute  disease,  and  during  which  time  I  have  seen 
her,  at  least,  twice  every  week.  Bellows  murmur, 
coincident  with  the  first  sound,  heard  h)udest  at 
the  base  and  in  the  course  of  the  aorta — swell- 
ing of  the  lower  extremities  so  as  to  require 
shoes  two  numbers  larger — little  oppression  of 
respiration,  except  on  rapid  fatigue,  when  the 
face  becomes  purple  and  congested,  and  the  ex- 
tremities pale  ;  frequent  headache  ;  assimilation 
good  ;  tendency  to  corpulency  ;  appetite  always 
good  ;  excretory  functions  well  performed  ;  pulse 
•  eighty,  not  strong,  split,  irregular,  intermittent 
from  one  to  ten  times  per  minute  often  when  in 
repose  ;  much  more  frequently  intermittent  in 
sleep  than  when  awake  ;  murmur  audible,  but  the 
first  sound  is  of  the  tricuspid  ;  diagnosi&j  thick- 
ening and  roughening  of  aortic  walls  ;  mitral 
insufficiency  slight  ;  hypertrophy  of  left  ven- 
tricle. 

4.  Theory  of  Diagnosis. — By  exclusion  ;  the 
aortic  valves  shut  back  distinctly  :  murmur  pro- 
pagated upwards,  not  coincident  with  second 
sound  ;  hence  aortic  valves  are  competent ;  no 
jugular  pulse,  hence  tricuspid  not  incompetent. 

By  the  thickened  walls  of  aorta,  left  ventricle 


THEIR    DIAGNOSIS    AND    TREATMENT.  29 

is  always  overtasked  ;  hence  hypertropied  ;  and 
from  excessive  work  and  the  resistance  of  the 
thickened  aorta,  we  have  momentary  forgetful- 
ness  of  the  heart  (oubiie  du  muscle),  hence  inter- 
mittent pulse  and  irregular  pulse.  The  blood  is 
impelled  with  diminished  force,  in  consequence 
of  inelastic  aorta  ;  hence  there  is  capillary  en- 
gorgement and  cellular  infiltration. 

5.  Lastly  :  Theory  of  mitral  incompetency  : 
the  murmur  not  heard  loudest  at  apex  ;  were  the 
murmur  only  mitral,  it  would  be  loudest  at  apex  ; 
but  it  is  a  composite  murmur,  composed  of  ele- 
ment a,  aortic  murmur,  element  Z>,  mitral  murmur, 
the  two  absolutely  synchronous,  but  a  very  much 
louder  than  6,  so  that  by  comparison  total  mur- 
mur is  heard  loudest  in  the  direction  of  the  aorta. 

6.  The  quick  exhaustion,  the  purple  face  after 
exercise,  the  almost  daily  headache,  without  or 
with  constipation  indifferently,  the  inability  to 
endure  close  rooms  or  large  assemblies,  are  so 
many  affirmative  signs  of  mitral  disease.  Add  to 
this,  the  mitral  murmur  is  heard  with  extreme 
distinctness  as  high  as  under  the  middle  of  left 
clavicle,  and  under  angle  of  left  scapula  ;  lower 
toned  than  over  aorta,  because  it  is  a  lower  and 
different  murmur.  Increased  second  sound  of 
pulmonary  artery  can  not  be  made  out  positively. 


30  DISEASES    OF   THE   HEART  : 

Treatment, — Mrs.  B.  has  taken  abont  a  quart 
of  compound  spirits  of  lavender,  and  four  ounces 
of  spirits  of  ammonia,  about  one  ounce  of  qui- 
nine, about  six  hundred  aloetic  pills,  has  been 
bled  at  the  arm  twice,  four  to  six  ounces  for 
angina  pectoris  with  fever,  has  been  dry-cupped 
and  leeched  at  the  precordia  for  pain  in  the 
heart  during  fever,  has  taken  digitalis  occasion- 
ally for  excessive  rapidity  of  heart-beats,  has 
taken  large  quantities  of  bitartrate  of  potassa  as 
a  diuretic,  for  swelling  of  feet  and  legs,  and  this 
with  a  cathartic  of  oleum  ricini  has  always 
afforded  immediate  relief  to  the  circulation  with* 
out  impairing  health.  She  has  taken  perhaps 
ounces  of  muriatic  acid  in  three  drop  doses  after 
eating,  to  promote  digestion,  which  for  the  last 
three  years  has  been  painful  without  the  acid. 
(The  hint  concerning  muriatic  acid  in  dyspepsia, 
occasioned  by  organic  disease,  I  get  from  Trous- 
seau.) 

8.  Result, — Her  present  condition  is  not  unsat- 
isfactory, when  the  incurable  nature  of  the  affec- 
tion is  considered.  The  hypertrophy  has  greatly 
increased  :  there  is  more  frequent  complaint  of 
uneasiness  about  the  heart ;  fatigue  is  not  so  well 
borne  ;  digestion  is  accomplished  with  more  diffi- 
culty ;  constipation  is  habitual ;  hematosis  is  less 


THEIR    DIAGNOSIS    AND     TREATMENT.  31 

complete  ;  the  muscles  are  becoming  flabby  ;  the 
extremities  do  not  swell  so  much  as  formerly, 
because  assimilation  is  less  active,  but  on  the 
whole  she  seems  in  pretty  good  health,  and  by 
treating  symptoms  as  they  arise,  according  to 
rational  ideas  now  possessed  by  the  profession, 
she  may  live  yet  many  years  ;  perhaps  ten,  or 
even  twenty,  but  without  constant  care  and  close 
observation,  she  might  die  in  a  few  months,  that 
is,  simply  by  leaving  the  disease  to  take  its  own 
course.  The  object  of  treatment  is,  in  this  case, 
to  diminish  the  labor  the  heart  has  to  perform, 
by  guarding  the  integrity  of  the  functions  of  the 
skin,  lungs,  alimentary  canal,  renal  organs,  liver, 
etc.,  and  last,  but  far  from  least  of  all,  the 
nervous  system,  by  preventing  mental  and  moral 
disturbances,  and  keeping  all  causes  of  grief,  de- 
pression, anxiety  and  hopeless  desires  out  of  the 
way.  Late  physiological  researches  have  made 
it  probable  that  no  causes  are  so  potent  in  has- 
tening the  fatal  course  of  organic  disease  of  the 
heart  as  those  which  act  reflexly  from  impres- 
sions made  on  the  nerves  of  special  sense  ;  and, 
on  the  other  hand,  through  these  same  means  the 
advance  of  heart  disease  may  be  greatly  retarded 
and  occasionally  held  at  a  stand-still  for  months 
or  years. 


32  DISEASES    OF   THE   HEART  : 

9.  Summary, — Is  there  a  certain  infallible  sign 
pathognomonic  of  incompetency  of  the  mitral 
valves?  I  do  not  believe  there  is  any  one  sign 
or  symptom  on  which  we  can  rely.  But  if  there 
is  a  murmur  heard  loudest  above  the  left  nipple, 
synchronous  with  the  heart's  impulse  against  the 
ribs,  and  at  the  same  time  there  is  increase  in  the 
intensity  of  the  second  sound  of  the  pulmonary 
artery,  (heard  in  the  second  left  intercostal  space, 
about  half  an  inch  from  the  sternum,  and  propa- 
gated directly  upwards),  it  is  as  certain  as  any- 
thing can  be  that  there  is  mitral  regurgitation. 
But  this  increased  second  pulmonic  sound  cannot 
always  be  made  out ;  still  we  cannot  say,  there- 
fore, that  the  diagnosis  cannot  be  made  ont.  It 
cannot  be  made  out  with  the  same  rigid  cer- 
tainty, but  it  can  be  made  so  clear  as  not  to 
leave  a  reasonable  doubt.  For  example  :  the 
murmur  is  heard  above  the  nipple,  the  pulse  alike 
weak  in  both  wrists,  patient  not  seeming  in  good 
condition  as  to  blood-making  power,  uncomfort- 
able feeling  in  the  chest,  quick  exhaustion  and 
lividity  of  face  on  rapid  exercise,  hypertrophy 
of  heart. 

10.  With  two  or  three  of  these  signs  well  estab- 
lished, we  are  sure  of  mitral  regurgitation  ;  a 
persistently  weak,  irregular  or  intermittent  pulse 
adds  to  the  certainty  of  the  affection. 


THEIR    DIAGNOSIS    AND    TREATMENT.  33 

a.  All  that  is  known  of  the  cause  of  intermit- 
tent pulse  may  as  well  be  suggested  here,  as  there 
will  be  constant  occasion  of  naming  it,  to  aid  in 
explaining  organic  lesions.  The  proximate  cause 
of  intermittent  pulse  is  arrest   of  the   systolic 
movement  of  the  heart,  and  the  remote  cause  of 
this  arrest  is  a  difficult  and  unsolved  problem  in 
pathology  ;   but  there  is  reason   to   believe   its 
origin  lies  rather  in  a  lesion  of  some  portion  of 
the  cerebro-spinal  axis,  than  in  any  alteration  in 
the  structure  of  the  heart  itself.      This   inter- 
mittent pulse  is  the  clue  that  leads  us  to  the  re- 
mote cause  of  the  organic  alterations  in  the  heart, 
viz.  :  a  primary  alteration  of  the  molecular  sub- 
stance of  those  portions  of  the  brain  and  cord 
which  preside   over  nutrition   and  elimination. 
This  is  not  an  attempt  at  an  explanation  of  the 
efficient  cause  of  intermittent  pulse,  but  a  dim 
suggestion  as  to  the  places  in  which  that  cause  is 
to  be  sought.     It  seems  sometimes  to  depend  on 
some  obstruction  acting  like  a  valve  at  the  ori- 
fice of  the  aorta.     The  ear  is  conscious  of  a  sys- 
tolic movement,  and  of  its  arrest  when  about  to 
be  completed  ;  and  during  this  momentary  arrest 
there  is  neither  sound  nor  murmur,  but  the  blood 
itself  seems  to  stand  still  in  the  whole  arterial 
system  ;  and,  indeed,  it  no  doubt  does,  for  the 
arrest  occurs  directly  after  the  diastole,  and  ex- 

D 


34  DISEASES   OF  THE   HEART  : 

tends  not  only  over  the  pause  between  that  and 
the  systole,  but  also  occupies  the  period  of  part 
or  all  of  the  systolic  movement ;  and  sometimes 
the  arrest  is  longer  than  a  complete  pulsation. 
In  the  latter  case,  there  is  a  sense  of  suffocation, 
attended  with  feeling  of  profound  exhaustion, 
and  a  feeling  of  *'  waves^'  in  the  brain,  wliich 
latter  feeling  interrupts  consciousness,  and  even 
sensation,  for  an  appreciable  instant.  The  pa- 
tient often  seems  abstracted  or  pre-occupied, 
and  gives  postponed  and  undecided  answers 
to  simple  questions,  from  inability  to  decide 
quickly  and  respond  promptly,  because  the  brain, 
from  unequal  supply  of  red  blood  is  not  always 
ready  to  command. 

h.  Intermittent  pulse,  considered  by  itself,  is 
without  significance  in  the  present  state  of 
knowledge  ;  but  taken  in  connection  with  hy- 
pertrophy of  the  left  ventricle,  mitral  incompe- 
tency and  direct  aortic  murmur,  it  still  adds  ^to 
the  dangerous  import  of  other  symptoms.  It 
aids  us  in  the  discrimination  of  aneurism  from 
valvular  affection  ;  for  in  the  former  the  pulse 
may  be  absent  from  one  wrist,  but  not  intermit- 
tent in  both  ;  while  in  valvular  disease  nothing 
is  more  common  than  intermittent  pulse.  If  there 
is  aneurism  and  the  pulse  is  intermittent,  we  may 
be  sure  there  is  valvular  disease  also ;   and  it 


THEIR   DIAGNOSIS   AND   TREATMENT.  35 

will  be  quite  probable  that  the  mitral  and  aortic 
valves  are  incompetent,  particularly  the  mitral. 
There  is  an  intimate  relation  between  the  fre- 
quency of  the  hearths  beats  and  intermittent 
pulse.  Under  the  immediate  effect  of  a  dose  of 
ammonia  and  lavender,  the  intermittence  will 
disappear.  It  seldom  or  never  occurs  when  the 
pulse  is  above  85.  It  is  very  common  when  the 
pulse  sinks  below  75,  either  from  unknown 
causes,  or  under  the  influence  of  digitalis.  Yet, 
if  there  be  no  organic  disease,  digitalis  will  not 
develope  the  intermissions  ;  but,  however  exten- 
sive the  organic  lesion,  cardiac  stimulants,  during 
their  action,  abolish  the  intermission. 

a.  It  is  remarked  above,  that  "  it"  (intermit- 
tence) "  seldom  or  never  occurs  when  the  pulse 
is  above  85."  This  needs  explanation  to  seem 
exact.  It  is  understood  that  the  patient  is  in 
repose  ;  not  under  the  influence  of  any  mental, 
moral  or  bodily  excitement,  and  that  the  heart  is 
not  driven  beyond  the  limit  of  endurance,  {a)  by 
some  temporary  stimulus,  for  example  :  excessive 
indulgence  in  stimulating  drinks  ;  {h)  by  violent 
exercise,  such  as  running  uphill,  or  with  all  pos- 
sible speed  ;  (c)  by  fright  or  anger  ;  {d)  by  mania, 
or  delirium  tremens  ;  (e)  by  the  agony  of  angina 
'pectoris^  and  the  violent  motions  of  desperation 
in  the  effort  to  breathe,  such  as  beating  the  air, 


36  DISEASES   OF   THE  HEART  : 

clutching  the  throat,  rapid  change  of  position, 
etc.,  etc.     Under  any  of  these  unusual  circum- 
stances or   conditions,  the  pulses  will   "  hang,'' 
or  intermit,  even  while  the  ventricles  succeed  in 
accomplishing  even  120  beats  a  minute,  as  in 
Case  3  below  ;  but  in  such  cases,  when  the  usual 
condition  of  the  patient,  as  to  repose,  etc.,  re- 
turns, the  pulse  will  become  slower  ;  the  inter- 
missions will  give  place  to  simple  irregularity  in 
time  and  tone,  and  finally  under  remedies  pro- 
perly selected  and  graduated,  the  pulse  will  be- 
come regular  in  time  first,  and  (if  the  dilatation 
of  the  heart  is  not  too  far  advanced,  or  if  the 
fatty  degeneration  be  only  incipient,)  soon  after 
in  tone  ;  but  if  the  sedative — say  digitalis — be 
continued  until  the  pulse  falls  below  70,  though 
it  be  full  and  strong,  the  intermittence  will  re- 
turn, either  as  to  a  part  of  a  systole,  while  the 
pulse  in  the  intervals  of  the  intermissions,  say  for 
ten,  twenty,  forty,  or  even  a  hundred  beats,  may 
be  regular  in  time  and  tone. 

b.  When  the  heart  is  affected  with  organic 
disease,  excessive  increase  of  its  function  from 
external  causes  develope  irregular,  remittent  and 
intermittent  pulse  ;  excessive  retardation  in  the 
heart's  beats  induce  remittent  and  intermittent, 
but  not  otherwise  irregular  pulse.  It  is  not 
affirmed  that  similar  causes  never  induce  similar 


THEIR  DIAGNOSIS   AND   TREATMENT.  37 

states  of  the  pulse  in  persons  in  good  health,  free 
from  anemia,  and  free  from  organic  disease ; 
but  one  may  venture  to  remark  that  such  a  result 
is  at  least  improbable,  and  is  rarely  observed, 
though  sought  for  with  great  diligence.  The 
rhythm  of  the  heart  is  so  hedged  about  by  all  in- 
fluences, that  any  material  disturbance  is  almost 
inconceivable  in  the  absence  of  alteration  of  the 
blood  as  to  quality  or  quantity  in.  special  locali- 
ties, (local  congestions  or  local  anemias,)  or  of 
abnormities  of  the  heart,  arteries,  or  cerebro 
spinal  axis.  But  respectable  gentlemen  and 
respectable  authors  assert  that  intermittent  pulse 
'per  se  is  no  evidence  of  a  pathological  condition 
anywhere.  One  must  be  permitted  to  doubt  the 
essential  truth  of  unproved  affirmations.  Inter- 
mittent pulse  is  not  a  normal  condition,  and  if 
persistent  independently  of  volition,  under  cer- 
tain definite  conditions,  such  as  those  suggested 
above,  it  cannot  fail  to  be  of  grave  significance. 

c.  There  are  rare  cases  of  rhythmical  inter- 
mittence,  depending  on  some  congenital  abnor- 
mity, and  there  are  well^  attested  cases,  but  en- 
tirely exceptional,  in  which  the  systoles-are  some- 
what under  the  control  of  volition,  and  in  which 
intermittence  can  be  caused  by  mere  volition  ; 
but  such  cases  must  be  acknowledged  to  be  ab- 


B8  DISEASES   OF   THE   HEART  : 

normal,  and  they  are  so  rare  that  they  may  be 
omitted  in  diagnosis. 

d.  The  irregularity  of  the  heart  in  anemia  or 
spanaemia  of  any  kind,  is  not  inconceivable,  on 
the  theory  here  suggested. 

e.  The  normal  condition  of  the  heart  can  be 
normally  performed  only  when  the  organ  is 
sound  in  structure,  and  supplied  with  proper 
nutrition  in  proper  quantity,  and  when  it  has 
natural  or  healthy  blood  to  exercise  its  function 
upon,  and  in  quantity  proportional  to  its  dynamic 
structure.  Depraved  blood  supplied  to  the  cor- 
ronary  arteries  may  cause  both  irregularities  and 
pain  :  even  spasm,  genuine  angina  pectoris^  may 
be  produced  from  the  same  cause.  Anemic  pa- 
tients often  complain  of  uneasiness  and  even  pos- 
itive pain  about  the  heart,  and  I  have  seen  re- 
cently a  case  of  anemia  in  which  there  was  fixed 
pain  in  the  third  left  interspace  close  to  sternum. 

Precordial  uneasiness  in  anemic  subjects,  is  as 
constant  a  symptom  as  irregular  and  feeble  pulse  ; 
and  there  is  every  reason  to  believe  this  pain 
and  this  uneasiness  ara  the  results  of  defective 
nutrition' of  the  heart  itself;  and  it  is  quite  cer- 
tain, as  the  anemic  condition  disappears,  as 
red  blood  discs  increase  in  number,  the  uneasiness 
and   pain  diminish  and  disappear  at  the  same 


THEIR   DIAGNOSIS   AND   TREATMENT.  39 

time  with  the  irregular  pulse,  and  the  complete 
restoration  of  the  blood. 

9.  Pain  is  probably  always  the  result  of  abnormal 
or  defective  nutrition  ;  and  uneasiness  is  pain  in 
a  less  accented  degree. 

h.  Finally,  extreme  excitement  and  extreme 
depression  develope  intermittent  pulse  from  the 
same  cause — defective  nutrition  and  innervation, 
either  relative  or  absolute  ;  but  in  repose  the 
pulse  seldom  or  never  intermits,  unless  it  falls 
below  70  per  minute,  and  then  irregularity  is  less 
marked  than  remission  or  intermission. 

11.  In  mitral  regurgitation  the  heart  increases 
more  in  width  than  length.  It  is  important, 
when  there  is  any  doubt  of  the  degree  of  semi- 
lunar incompetency  attending  the  mitral  defect, 
to  take  this  fact  into  consideration  ;  for,  if  the 
heart  is  not  sensibly  elongated,  the  aortic  valvular 
incompetency  will  be  very  slight  or  entirely  ab- 
sent. 

12.  Treatment, — a.  For  m/itral  regurgitation 
a  great  deal  of  passive  exercise  in  the  open  air 
is  of  the  first  importance.  This  can  be  accom- 
plished by  riding,  or  sea  voyages.  Walking 
should  not  be  recommended,  nor  indeed  any 
considerable  voluntary  exercise  ;  but  passive  ex- 
ercise cannot  be  too  much  or  too  constantly  in- 
sisted upon. 


40  DISEASES    OF   THE    HEART  : 

h.  Well  ventilated  sleeping-room — that  is,  a 
room  in  which  air  is  admitted  through  an  open- 
ing of  two  square  feet,  with  no  gauze  or  curtain 
over  it ;  comfortable  warmth  to  be  maintained 
by  bcd-clotheSj  not  by  the  exclusion  of  the  at- 
mosphere. 

c.  A  quiet  mind  and  an  even  temper  aid 
greatly  in  prolonging  life,  and  the  prevention  of 
suffering. 

d.  A  meat  is  better  than  a  vegetable  or  mixed 
diet ;  no  objection  to  fruit  ;  diet  spare. 

e.  Arterial  stimulants  must  be  avoided. 

/.  Tobacco  is  very  injurious  in  all  kinds  of 
heart  disease. 
g.  Coffee  is  seldom  tolerated  with  impunity. 

A.  If  the  pulse  runs  above  80,  digitalis  and 
solution  of  perchloride  of  iron  are  indicated. 

/.  If  the  pulse  is  very  weak,  heef  juice  must  be 
given  freely,  say  a  pint  a  day. 

k.  If  the  patient  is  strong  and  full-blooded,  a 
purge  should  be  given  whenever  there  is  any 
tendency  to  congestions  or  effusions  ;  the  non- 
stimulatino-  diuretics  are  always  serviceable, 
given  two  or  three  days,  at  intervals  of  two  or 
three  days. 

/.  Frequent  bathing  is  much  and  imperatively 


THEIR    DIAGNOSIS    AND    TREATMENT.  41 

required  in  almost  all  afFections  of  the  heart  and 
arteries  ;  plain  water,  hot,  is  quite  as  good  as 
any  medicated  bath. 

The  labor  of  the  heart  must  be  lightened  from 
time  to  time,  in  bad  cases,  by  purging,  by  diure- 
tics, and  even  by  leeching  and  cupping  over 
the  base  of  the  heart,  or  by  leeches  at  the  anus. 

It  is  doubtful  whether  bleeding  at  the  arm,  or 
in  any  considerable  quantity,  would  ever  be  indi- 
cated in  mitral  regurgitation.  The  angina  pectoris^ 
which  comes  on  with  such  violent  paroxysms, 
will  yield  to  dry  cups  in  two  or  three  minutes, 
quite  as  certainly  as  to  scarifications  or  leeches 
followed  by  cups. 

13.  Case  3.    On   the  12th   of  February   last, 

Mr. Turk  street,  with  mitral  disease  and 

aortic  incompetency,  had  a  most  frightful  par- 
oxsym.  His  face  and  hands  were  purple  ;  he 
beat  the  air  wildly  with  his  arms  :  suffocation 
seemed  imminent ;  his  pulse  had  ceased  ;  the 
heart  beat  130  per  minute  ;  irregular  and  inter- 
mittent. He  was  bathed  in  a  sweat  of  agony, 
gasping  for  breath,  with  doors  and  windows 
open.  Four  cups  were  placed  over  the  region  of 
the  heart,  but  before  the  fourth  one  had  been  set, 
his  paroxysm  began  to  subside,  and  within  less 
than  five  minutes,   his  pulse  became   tolerably 


42  DISEASES   OF   THE    HEART  : 

regular  at  the  wrist,  and  the  heart  beats  had 
fallen  to  120,  and  much  increased  in  strength. 
The  cups  were  left  on  three  hours,  and,  on  being 
removed,  contained  more  than  a  drachm  each  of 
serum  and  blood,  which  had  been  drawn  through 
the  skin. 

14.  I  am  not  quite  sure  the  cups  would  not  do 
as  well  on  some  other  part  of  the  body  ;  indeed, 
there  is  reason  to  believe  they  would,  inasmuch 
as  their  beneficial  effect  must  be  principally  re- 
flex ;  but  the  patients  always  want  something 
done  about  the  region  of  ihe  heart,  where  they 
say  the  anguish  centres.  ^ 

15.  I  said  above,  A.  "  If  the  pulse  run  above 
90,  digitalis  and  solution  of  perchloride  of  iron 
are  indicated."  If  there  is  bronchial  irritation, 
with  dark  muco-sanguineous  expectoration,  I 
would  add  tartrate  of  antimony,  in  small  doses, 
to  the  digitalis  and  iron. 

a.  The  iron  and  antimony  should  be  alternated 
with  the  digitalis,  instead  of  being  given  at  the 
same  time.  A  drachm  of  the  solution  of  the  per- 
chloride of  iron  with  five  grains  of  potassio  tar- 


*  I  sliaU  have  occasion  in  the  following  pages  to  allude 
to  mitral  disease  many  times,  and  will  attempt  to  explain 
the  mode  of  death  in  this  affection  in  some  subsequent  para- 
graph. 


THEIR   DIAGNOSIS   AND   TREATMENT.  43 

trate  of  antimony  in  a  pint  mixture,  composed  of 
equal  parts  of  distilled  water  and  simple  syrup, 
will  constitute  a  preparation  of  which  a  teaspoon- 
ful  or  more  may  be  given  every  two  hours,  with 
decided  diuretic  and  tonic  effect.  If  there  is  albu- 
minuria, it  modifies  or  arrests  it  very  promptly, 
unless  the  kidneys,  one  or  both,  are  acutely  in- 
flamed. If  such  is  the  case,  leeches,  or  scarifica- 
tion and  cups  over  the  kidneys,  followed  by  warm 
fomentations  will  be  required  before  the  diuretic 
effects  of  the  iron  can  be  realized. 

b.  The  passage  of  the  iron  into  the  circulation 
and  through  the  kidneys  should  be  verified  by 
adding  gallic  acid  to  the  urine  subsequently 
voided,  when  if  iron  be  present,  the  urine  will 
instantly  become  inky.  I  constantly  employ  this 
mixture  of  iron,  or  the  mixture  with  the  antimony 
omitted,  as  a  tonic,  diuretic,  and  a  sedative  to  the 
heart ;  and  it  seems  to  me  to  greatly  aid  the 
action  of  digitalis.  The  perchloride  of  iron  ad 
ministered  thus  largely  diluted,  is  probably  both 
preventive  and  curative  of  anemia,  and  thus  it 
must  tend  to  protect  and  restore  the  heart  itself 
in  the  overwork  to  which  it  is  constantly  subject 
wl\en  organically  affected. 

c.  It  requires  a  strong  will,  an  intelligent  voli- 
tion on  the  part  of  the  patient  to  persist  in  a 


44  DISEASES   OF    THE  HEART  : 

proper  and  rational  diet  in  affections  of  the  heart. 
For  this  reason,  it  would  seem  fit  that  he  should 
be  early  informed  of  the  nature  and  tendency  of 
his  disease,  and  the  reasons  of  the  modifications 
which  are  requisite  in  diet,  exercise,  etc.  It  is  a 
mistake  to  suppose  a  patient  can  be  made  mate- 
rially worse  by  being  informed  of  his  true  condi- 
tion ;  the  deterioration  will  be  only  temporary, 
and  when  the  first  fright  or  dread  has  passed  off, 
the  patient  will  be  in  a  better  condition  for  treat- 
ment than  when  oppressed  with  vague  and  irra- 
tional fear^,  or  hopes  which  he  will  too  soon 
learn  are  baseless  or  improbable.  No  medication 
will  avail,  without  the  most  carefully  and  ration- 
ally regulated  diet,  both  as  to  quantity  and 
quality. 

d.  Nothing  is  more  fatal  than  the  theory  of 
treatment  which  proposes  absolute  rest  in  bed, 
with  low  vegetable  diet  for  organic  diseases  of 
the  heart.  It  will  hasten  death  in  almost  every 
case,  by  the  additional  injury  it  entails  on  the 
heart's  substance,  by  deteriorating  the  quality  of 
the  blood  supplied  to  the  coronary  arteries,  and 
to  the  ganglia,  which  preside  over  cardiac  in- 
nervation. 

e.  What  we  want  is  to  diminish  the  whole 
weight  of  the  body,  blood  and  all,  while  the  Mood 


THEIR    DIAGNOSIS    AND    TREATMENT.  45 

is  maintained  at  its  normal  standard  of  excel- 
lence, or  as  nearly  so  as  possible  with  the  con- 
stant progress  of  a  disease  whose  tendency  is 
always  fatal. 

/.  I  said  (12  e.)  arterial  stimulants  must  be 
avoided  ;  this  needs  qualification.  For  example, 
the  following  : 

Case  5. — The  patient,  now  under  treatment, 
has  mitral  regurgitation,  with  all  its  attendant 
and  consequential  ills;  hypertrophy  and  dilatation 
of  both  ventricles,  aortic  semilunar,  and  tricuspid 
insufiiciency,  oedema  of  the  lungs,  and  cough  with 
venous  blood-tinged  mucous  :  dropsy  universal, 
orthopnoea  uninterrupted,  dyspnoea  so  great  as 
to  induce  almost  constant  perspiration,  g.  Here 
are  the  clinical  symptoms  observed  at  last 
visit.  A  large-framed  man,  aged  35,  is  sitting 
almost  perpendicular  in  bed,  (his  constant  atti- 
tude,) his  face  is  moist,  his  breathing  labored, 
cough  frequent,  venous  blood-tinged  expectora- 
tion, universal  dropsy,  everywhere  in  lungs 
coarse  moist  rales,  and  occasional  whistling  res- 
pirations— no  first  sound  at  apex,  but  an  indis- 
tinct murmur  ;  intensely  increased  second  pul- 
monic sound  heard  over  third  left  cartilage  ; 
aortic  second  sound  replaced  by  a  murmur  heard 
loudest  on  sternum,  between  ends  of  third  ribs — 


46  DISEASES   OF  THE   HEART  : 

aortic  regurgitant  murmur — tbe  radial  pulse  full, 
strong,  visible,  large,  resisting  and  regular,  and 
120  ;  the  epigastric  pulsation  of  abdominal  aorta 
is   much    more  forcible   and  visible  than  apex 
impulse  ;  the  carotids  throb  ;  when  the  two  in- 
dex fingers  are  placed  on  the  subclavian  arteries 
in  the  subclavian  triangles,  the  arteries  strike 
the  finger  ends  at  each  systole,  with  the  abrupt 
tap  of  a  hammer — a  short,  quick,  flat,  decided 
blow.     Mechanism   of   first  sound    appreciated 
by  the  ear  at  apex,  but  no  sound  ;  hearths  im- 
pulse two  inches  to  the  left  of  nipple  in  fifth 
and   sixth  interspaces  ;    systolic   thrills,  to  the 
touch,  all  over  the  lieart,  especially  in  third  and 
fifth  interspaces,  and  third  right  space  close  to 
sternum.     Jugular   pulse ;    basic    systolic    mur- 
mur not  audible  above  the  second  right  cartilage  ; 
heart  beats  exceedingly  tumultuous,  with  mode- 
rate but  marked  heaving   impulse   at  the   pre- 
cordia  ;  large,  full  veins   everywhere  on  arms 
and  legs  ;  nails  purple  ;  a  semi-livid  hue  to  the 
whole  body.     Copious  pink  urates  have  been  de- 
posited for  months  ;  liver  much  enlarged  ;  head* 
ache  constant,  but  mind  clear  ;  appetite  absent  ; 
digestion    and   assimilation  very   bad  ;    bowels 
constipated  ;  pulse  120  ;  temporal  arteries  crawl 
like  worms. 

h.  Now,  I  think  there  can  be  no  question  of 


THEIR   DIAGNOSIS   AND   TREATMENT.  47 

diagnosis  in  this  case,  nor  of  prognosis.  Death 
is  certain  and  imminent.  In  this  case,  though 
purgatives,  diuretics,  expectorants  and  even  dia- 
phoretics and  perhaps  precordial  depletion  are 
indicated,  and  absolutely  necessary  to  the  pro- 
longation of  life,  even  for  a  few  days,  yet  stimu- 
lants, and  tonics,  and  concentrated  nutrients  are 
equally  and  quite  as  imperatively  required. 

And  this  is  the  treatment  pursued,  and  directly 
it  is  suspended,  even  for  a  few  hours,  all  the 
symptoms  and  subjective  sufferings  are  worse  and 
much  less  tolerable. 

i.  Here  whiskey,  ammonia,  especially  the  mu- 
riate, [because  while  it,  the  muriate  of  ammonia, 
unloads  the  liver  and  fortifies  the  heart  indirectly, 
if  not  directly,  it  certainly  diminishes  the  tumult 
of  the  heart,  and  steadies  and  retards  its  beats,] 
and  perchloride  of  iron,  and  elixir  of  bark,  and 
beef  juice,  and  egg-nogg  may  be  given  not  only 
with  impunity,  but  with  great  advantage,  and 
well-founded  expectation  of  adding  weeks,  or 
even  months,  to  life  by  their  judicious  use.  Such 
a  case  should  occupy  a  room  twenty  feet  square 
and  fifteen  feet  high,  and  the  mercury  should 
stand  at  60,  while  two  large  windows  should  re- 
main wide  open  day  and  night.  He  should  also 
be  wheeled  about  the  room  in  a  chair,  that  he 


48  DISEASES   OF   THE   HEART  : 

might  have  the  benefit  of  passive  exercise  in  the 
prolongation  of  life. 

I  am  the  more  minute  in  all  this  detail  of 
treatment  because  it  is  applicable  to  all  forms  of 
heart  disease,  with  obvious  restrictions  and  limi- 
tations. 


CHAPTER  IV. 

Disease  of  the  Semilunar  Valves  of  the  Aorta. 
Direct  and  Regurgitant  Murmurs — Differential 
Diagnosis  of.  Treatment  of  Disease  of  the  Aortic 
Val^^s,  and  its  CompijcAtions. 

1.  The  time  and  location  at  which  the  murmur 
is  heard  mark  the  lesion,     [Brown.] 

2.  A  murmur  with  the  heart's  systole,  louder 
in  the  direction  of  the  aorta  than  in  any  other 
direction,  indicates  roughened  semilunar  valves 
of  aorta,  [provided  that  the  chest  is  not  deformed, 
and  there  is  no  anemia.] 

3.  A  murmur  coincident  with  the  second  sounds 
or  replacing  second  sound,  heard  loudest  between 
third  and  fourth  ribs,  left  side,  and  close  to  the 
breast-bone,  and  hence  downwards  indicates 
aortic  regurgitation. 

4.  The  regurgitant  aortic  murmur  is  often 
heard   distinctly   down   the   sternum   from    the 


THEIR    DIAGNOSIS    AND   TREATMENT.  49 

fourth  rib,  and  when    so  heard  can  only  be  con. 
founded  with  tricuspid  murmur,  or  the  murmur  of 
of  aneurism  of  the  descending  aorta.     It  can  be 
distinguished   from   the    tricuspid    murmur  :    a, 
because  in  the  murmur  from  incompetency  of  the 
tricuspid  there  is  jugular  pulse  coincident  with 
hearts  systole,  while  the  aortic   regurgitant  is 
coincident  with  the  diastole  of  the  heart,     h,  in 
roughened  but  not  incompetent  tricuspid  valves, 
the  murmur  is  synchronous  with  the  hearths  dias- 
tole, that  is  with  the  second  sound,  and  is  propo- 
gated  down  the  sternum  ;  hence  by  auscultation 
and  percussion  alone,  aortic  regurgitation   and 
direct    tricuspid    murmur     cannot     be     distin- 
guished ;  and  it  is  probable  that  by  the  nature  of 
the  proposition  these  two  affections  can  never  be 
distinguished  in  this  manner  ;  but,  if  we  hear  the 
murmur  loudest  between   third  and  fourth  ribs, 
close  to  sternum  on  left  side,  coincident  with  the 
heart's  diastole,  or   the  second  sounds  (emitted  by 
still   healthy   pulmonic   valves,)    it   is  certainly 
aortic  regurgitation,  and  the  murmur  heard  down 
the  sternum  will  proceed  from  this  cause  alone, 
or  from  this  and  tricuspid  roughness  combined. 
But  as    the    tricuspid  roughness  is  of  infinitely 
less  consequence  than  aortic  valvular  incompe- 
tency, it   may  be  merged  in  the  latter  and  ig- 
nored in  tbo  diagnosis  and  the  treatment,  with- 

F 


50  DISEASES    OF   THE    HEART  : 

out  the  least  detriment  to  the  patient. 

c.  We  distinguish  aortic  regurgitant  murmur 
from  that  of  aneurism,  by  the  fact  that  the  mur- 
mur of  aneurism  is  always  synchronous  with  the 
heart's  systole^  while  tlie  regurgitant  murmur  is 
always  synchronous  with  the  diastole.  If  there  is 
any  difficulty  in  establishing  these  synchron- 
isms, on  account  of  rapidity  of  heart's  movements, 
it  can  be  remedied  by  giving  small  doses  of  digi- 
talis, every  half-hour,  until  the  pulsations  are 
reduced  to  sixty  or  seventy  beats  per  minute, 
when  the  discrimination  will  not  be  very  difficult. 

25.  There  may  or  may  not  be  dropsy  of  the 
extremities  in  aortic  regurgitation  ;  and,  if  the 
feet  and  legs  are  swollen,  this  condition  may 
be  irregularly  intermittent,  depending  upon  the 
diet,  activity  of  the  alimentary  canal,  or  of  the 
functions  of  the  skin  and  kidneys,  by  which  the 
circulation  may  be  so  far  relieved  as  to  prevent 
or  reduce  cellular  infiltration  of  the  extremities. 

26.  All  valvular  diseases,  in  fact  all  diseases 
of  the  circulatory  apparatus,  are,  iheoretically, 
likely  to  produce  dropsy  of  the  extremities.  But 
in  practice,  long  standing  cases  of  valvular  in- 
competency [three  years,  Walshej  have  been  seen 
in  which  there  was  no  oedema  of  the  extremities. 

a.  If  the  capillary  circulation  depend  upon  the 


THEIR    DIAGNOSIS    AND    TREATMENT.  51 

vis  a  fergo,  which  consists  in  the  ventricular  sys- 
tole,  reinforced  and  supplemented  by  arterial 
elasticity,  it  is  difficult  to  understand  -how  if  the 
vis  a  terfro  is  removed,  as  it  is  to  a  great  extent, 
in  incompetency  of  the  aortic  valves,  there  should 
not  be  uniformly  hemic  stasis  in  the  capillaries, 
and  consequential  serous  infiltration  of  the  ex- 
tremities, h.  In  point  of  fact,  I  believe  that  the 
cases  of  long  standing  in  which  dropsy  of  the  ex- 
tremities is  absent  are  exceptional. 

c.  The  following  sentences  of  Walshe  per- 
haps explain  the  frequent  absence  of  oedema 
in  this  affection.  ''  The  cerebral  capillaries  can 
only  be  affected  secondarily  through  the  pul- 
monary class  ;  and  the  systemic  capillaries  are 
much  in  the  same  position.  Regurgitation  may 
exist  to  the  highest  amount  without  oedema  of 
the  extremities."  Grant  that  arterial  pressure, 
aided  by  muscular  contractions,  valves  in  the 
veins,  and  diastole  of  the  right  ventricle,  might 
keep  the  blood  in  equable  and  uniform  motion 
through  the  capillaries,  still  how  could  the  arte- 
rial pressure  take  eflfect  and  urge  the  blood  to- 
wards the  apex  of  a  hollow  cone,  the  base  of 
which  remains  open,  as  it  does  in  aortic  incompe- 
tency.? Until  cases  are  cited  to  verify  assertion 
to  the  contrary,  it  will  still  be  probable  that  the 
amount  ofcedema  of  the  extremities  will  be  one  of 


52  DISEASES    OF   THE   HEART  : 

the  measures  of  the  degree  of  incompetency  of  the 
aortic  or  tricuspid  mitral  vatves.  "^ 

d.  The  sequential  hypertrophy  or  that  attending 
aortic  incompetency,  while  at  each  ventricular 
systole  it  increases  the  distension  of  the  aorta, 
and  while  this  very  distension  increases  the 
force  of  the  succeeding  recoil,  must  have  a 
tendency,  by  adding  to  the  impelling  force  of 
the  blood,  to  diminish  the  tendency  to  capil- 
lary stasis  and  transudation  ;  hence  hypertrophy 
in  aortic  regurgitation  is  alleviative  until  it 
becomes  excessive,  or  until  mitral  incompetency 
sets  in,  and  thus  retrograde  pressure  through  the 
pulmonic  vessels  on  the  right  ventricle,  and  so 
on  the  cavas,  and  their  venous  and  capillary 
tributaries,  annuls  the  benefit  of,  or  renders  in- 
jurious the  advancing  hypertrophy. 

e.  When  this  stage  is  reached,  the  advance  of 
hypertrophy  is  the  advance  of  the  whole  disease 
towards  a  fatal  termination. 

27.  Pain  in  the  region  of  the  heart  is  an  ex- 
ceptional symptom  in  either  mitral  or  aortic  val- 
vular disease.  There  is  always,  if  the  patient's 
attention  be  called  to  it,  a  sense  of  discomfort, 
fullness,  or  pressure,  or  weight,  or  unnatural  so- 
lidity about  the  lieart ;  and  when  aortic  valvular 
and  mitral  diseases  co-exist,  as  they  do  in  the 


*  See  Appendix,  "  Causes  of  Dropsy." 


THEIR   DIAGNOSIS    AND   TREATMENT.  53 

great  majority  of  cases,  the  sense  of  discomfort  is 
greatly  increased,  and  there  is  generally  consid- 
erable oppression  of  the  chest,  and  often  a  dry 
coughs  disposed  to  be  paroxysmal,  or  to  result 
from  fatigue  rather  than  to  be  continuous.  To 
persons  afflicted  with  aortic  regurgitation,  close 
rooms  are  intolerable  ;  any  weight  on  the  chest, 
or  tight  garments  compressing  the  thorax,  are 
unendurable,  without  great  suffering  ;  violent 
exercise  causes  lividity  of  face  and  hands,  and  a 
sense  of  imminent  suffocation.  The  patient  often 
feels,  on  ascending  a  hill  or  stairs,  as  though  he 
must  inevitably  fall  on  arriving  at  the  top,  and  in- 
stinctively seizes  something  for  support.  There 
are  occasional  flashes  of  oblivion  of  all  things,  sub- 
stantial or  abstract ;  a  sort  of  suspension  of  every 
trace  of  intellection  and  special  sense,  for  an 
appreciable  instant ;  there  is  reiterated  tendency 
to  heart  forgetfuhiess ;  that  is,  the  heart  seems 
inclined  to  rest,  and  is  re-aroused  by  a  sudden 
inspiration,  or  throwing  up  of  the  hands,  or  by  a 
start. 

28.  The  hypertropy  of  the  heart  that  attends 
this  disease  is  often  very  manifest  to  the  naked 
eye,  as  well  as  to  percussion.  The  ribs  are  seen 
to  be  sensibly  higher  over  the  left  than  right 
side  ;  the  hearths  impulse  is  felt  over  a  wider 
space,  and  more  to  the  left,  and  lower.     There  is 


54  DISEASES   OF   THE   HEART  : 

a  metallic  clang  to  the  systole,  and  especially  is  the 
clang  heard  over  the  beginning  of  the  pulmonary 
artery,  hetweeii  the  second  and  third  ribs,  left  side, 
close  to  the  sternum.  The  precordial  dullness  on 
percussion  is  increased  in  extent,  and  in  jecoral 
similarity.  The  j)ulse  should  be  diminished  in 
force,  in  consequence  of  regurgitation,  pure  and 
simple  ;  but  if  the  mitral  incompetency,  co-exist- 
ing with  that  of  the  semilunar  valves,  is  slight, 
and  the  hypertrophy  considerable,  the  pulse 
may  be  strong  and  full,  but  will  have  an  appre- 
ciable recoil,  sufficient  to  suggest  the  idea  of  a 
backward  current  in  the  artery.     In  short  : 

b.  The  aortic  semilunar  valves  are  certainly 
incompetent  when  tJiere  is  a  murmur  without  a 
sound,  prolonged  and  heard  above  the  base  of  the 
heart,  synchronous  with  the  hearts  diastole ;  and 
when  this  same  murmur  is  heard  at  the  same  time 
down  the  sternum,  there  being  no  jugular  pulse,  and 
when  there  is_  also  hypertrophy  and  dilatation  of  the 
left  ventricle, 

I  must  not  omit  the  sign  pathognomonic  of  Dr. 
Corrigan  :•  that  is,  visible  pulses  of  all  the  super- 
ficial arteries,  and  vermicular  onward  motion  of 
the  tortuous  arteries  ;  the  artery  moves  forward 
in  the  direction  of  its  axis — locomotion  of  the 
pulses — the  radials,  temporal  and  tibials,  where 


THEIR   DIAGNOSIS    AND    TREATMENT.  55 

they  run  nearest  the  surface,  are  those  in  which 
the  moving  pulses  are  most  frequently  visible  ; 
*'  but  in  highly  marked  cases,  the  carotid,  bra- 
chial, axillary,  femoral  and  external  iliac  arteries 
distinctly  present  it."  (Walshe.) 

But  although  there  are  few  or  no  cases  of  aortic 
incompetency  without  visible  pulses,  there  are 
certainly  many  cases  of  visible  pulses  without 
aortic  incompetency.  I  saw  a  case  not  many 
weeks  since,  in  which  all  the  superficial  pulses 
were  visible,  a  case  of  aortic  aneurism  and  hy- 
pertrophy of  left  ventricle,  in  which  the  pulse 
was  120,  when  uncontrolled.  The  patient  died 
of  rupture  of  the  aneurism  into  the  esophagus  ; 
the  aortic  valves  were  perfectly  competent,  tested 
by  water  poured  into  the  cut  aorta,  and  by  in- 
spection of  the  valves.  Though  always  present 
in,  visible  pulses  are  not  pathogomonic  of  semi- 
lunar incompetency. 

c.  Hypertrophy  of  left  ventricle  is  determined  by 
percussion^  locus  of  apex  impulse,  vigor  of  contrac- 
tion, 

d.  Dilatation  of  ventricle  is  determined  princi- 
pally by  clearness  and  quickness  of  the  systolic 
movement  of  the  heart ;  for  though  the  systolic 
sound,  first  sound,  be  abolished  by  mitral  and 
tricuspid  incompetency,  yet  the  systolic  movement 


56  DISEASES     OE   THE   HEART  : 

remains  as  a  determinable  fact,  and  occupies  an 
appreciable  time,  and  takes  place  in  -an  apprecia- 
ble manner ;  and  it  is  by  the  manner  and  time 
occupied  in  this  systolic  movement^  other  things 
not  opposing,  that  dilatation  of  the  ventricle  is 
made  out.  If  all  the  facts  mention^  in  para- 
graph h  are  present,  aortic  valvular  incompetency 
is  absolute,  (if  there  is  no  deformity  in  the  chest 
of  the  patient,  no  tumor,  etc..)  but  if  one  of  those 
facts  are  wanting,  the  diagnosis  lacks  demonstra- 
tion. For  example,  if  hypertrophy  and  dilatation 
are  absent,  incompetency  is  improbable.  If  the 
murmur  down  the  sternum  be  absent,  the  upper 
murmur  may  depend  upon  roughness  on  the  inner 
surface  of  the  aorta  ;  but  in  this  case,  the  murmur 
will  generally  be  hounded  hy  a  sound,  that  is,  wil 
terminate  in  the  click  of  closure  of  the  aortic 
valves,  though  not  always,  especially  if  there  is 
mitral  regurgitation,  fatty  degeneration  of  heart 
tissue,  constricted  mitral  orifice,  or  when  the 
aortic  valves  or  the  aorta  itself  is  thicker  and 
less  elastic  than  natural  ;  in  all  these  cases,  the 
pound,  though  its  mechanism  be  present,  may  not 
reach  the  most  practised  ear ;  but  the  diagnosis 
of  aortic  valvular  incompetency  is  made  certain 
only  by  the  concurrence  of  the  facts  mentioned 
above. 

29.  As  aortic  incompetency  and  mitral  incom- 


THEIR    DIAGNOSIS    AND    TREATMENT.  57 

petency  are  as|||^iate  affections,  the  treatment  of 
one  is  the  treatment  of  the  other,  under  limita- 
tions. 

a.  Aortic  incompetency,  in  its  beginning,  may 
exist  alone,  or  without  mitral  defect.  In  such 
case  the  lungs  will  not  have  become  congested,  as 
in  mitral  lesion,  and  we  shall  not  have  to  contend 
with  the  annoying  cough,  or  the  spitting  of  dark 
blood,  transuded  from  the  pulmonary  vessels. 
But  there  will  be  the  same  need  of  lessening  the 
labor  of  the  heart  by  all  means  consistent  with 
the  hygiene  of  the  whole  system.  For  example? 
in  aortic  incompetency,  absolute  quiet  is  indicated 
for  that  alone  ;  but  absolute  quiet  is  incompati- 
ble with  digestion  and  nutrition,  and  the  case 
would  terminate  fatally  all  the  sooner  in  conse. 
quence  of  a  low  grade  fever  which  would  be  gen- 
erated. The  treatment  is  rest,  as  to  voluntary 
exercise,  but  passive  exercise  in  the  open  air, 
without  a  day's  interval,  such  as  travelling  by 
stage  or  rail,  in  ordina-ry  vehicles,  or  on  horse- 
back ;  the  absence  of  all  excitement  and  annoy- 
ance ;  a  light  but  nutritious  diet.  The  patient 
may  eat  a  little  at  a  time,  four  times  a  day,  much 
rather  than  an  abundant  meal  twice  a  day. 
Small  meals  disturb  the  circulation  much  less 
than  large. 


58  DISEASES    OF   THE  HEART  : 

But,  UDfortunately,  few  persoi|j|^an  follow  the 
passive  exercise  treatment.  They  lack  the  means, 
or  they  are  hindered  by  family  ties,  or  the  dread 
of  being  away  from  friends,  or  a  disinclination  to 
this  species  of  exercise,  and  principally  would 
they  be  hindered  by  a  doubt  of  its  efficiency  : 
and  this  no  doubt  would  increase,  when  after 
several  months  they  found  themselves  no  better  ; 
whereas,  a  patient  should  be  abundantly  satisfied, 
in  almost  all  lesions  of  the  heart,  if  he  gets  no 
worse.  When  we  hold  an  affection  of  the  heart 
in  check,  we  accomplish  all  that  can  with  any 
reason  be  asked  of  us.  When  we  alleviate  symp- 
toms— not  entirely  remove  them^ — we  do  all  that  a 
tolerably  well  educated  patient  will  believe  pos- 
sible. We  can  prolong  life,  but  we  cannot  say 
to  our  patient  that  he  is  no  more  liable  to  death 
than  he  would  be  were  his  heart  perfectly  sound. 

d.  In  aortic  incompetency,  the  patient  is  liable 
to  sudden  attacks  of  fainting,  from  anger  or  vio- 
lent excitement,  or  over  exercise.  Absolute 
quiet,  free  exposure  to  the  air,  dry  cups  to  the 
precordia,  or  if  cups  are  not  at  hand,  a  few  drops 
of  boiling  water  over  the  base  of  the  heart,  or  a 
mustard  plaster  will  restore  the  circulation.  A 
copious  draught  of  cold  water  might  cause  instant 
death,   by  reflex  shock  to  the  already  exhausted 


THEIR   DIAGNOSIS   AND   TREATMENT.  59 

heart.  A  spoonful  of  brandy  and  water,  or  a  few 
drops  of  spirits  of  ammonia,  with  spirits  of  lav- 
ender and  water,  would  aid  immediate  restora- 
tion ;  hot  applications  to  the  soles  of  the  feet,  or 
leeches  to  the  end  of  the  alimentary  canal,  are 
slow  but  unobjectionable  temporary  remedies. 

The  bowels  must  never  be  constipated  for  a 
day  ;  this  can  be  avoided  by  taking  daily  at  bed- 
time  an  aloetic  or  compound  rhubarb  pill,  or  a 
pill  of  the  following  : 

a.  R.  Aloes,  Rhei,  Comp.  ext.  Colocynthidis, 
aa,  dr.  ij  ;  Ext.  Xucis  Vomicae,  scruple  j.  Mix, 
and  make,  according  to  art,  into  sixty  pills. 

29.  Formula  a  will  be  found  convenient  and 
efficient  in  almost  all  cases,  and  rarely  contra- 
indicated.  If  dropsy  should  occur,  either  general 
or  local,  it  is  to  be  treated  not  as  an  idiopathic 
dropsy,  id  est,  a  hydremia,  or  anemia,  but  it  must 
be  met  with  purgatives,  diuretics,  low  diet  and 
diaphoretics,  that  the  overloaded  circulation 
which  is  its  cause  may  be  relieved  as  soon  as 
possible  ;  and  to  assist  this  purpose,  absolute  rest 
should  be  enjoined,  and  the  hearths  action  dimin- 
ished with  small  doses  of  digitalis,  often  repeated, 
or  digitalis  alternated  with  aconite. 

Digitalis  has  been  objected  to  in  many  diseases 
of  the  heart  by  high  authorities,  (Corrigan,  Hen- 


60  DISEASES   OF   THE    HEART  : 

derson,  Walshe,  etc)  and  especially  in  aortic 
incompetency.  The  argument  against  it  is  this, 
and  nothing  more  : 

a.  Aortic  incompetency  admits  reflux  of  blood 
into  left  ventricle,  at  the  instant  when  the  direct 
current  is  entering  it  through  the  mitral  orifice  ; 
hence  the  ventricle  is  overloaded  and  gradually 
enlarged — dilated  and  hypertrophied— the  more 
frequent  the  heart  beats  the  less  the  opportunity 
for  regurgitation,  and  hence  the  less  the  ventri- 
cular engorgement  ;  but  digitalis  ''  slews'^  the 
heart  beats,  and  hence  allows  more  time  for 
aortic  regurgitation,  and  hence  increases  the  dila- 
tation of  the  ventricle. 

b.  Now,  all  this  is  true,  but  still  it  is  no  objec- 
tion to  the  guarded  use  of  digitalis.  The  argu- 
ment against  it  deals  with  logical  extremes,  and 
is  conclusive  against  digitalis  from  that  point  of 
view  ;  but  the  drug  should  be  given  to  slow  an 
excited  heart,  beating  with  excessive  frequency, 
say  more  than  90  per  minute,  but  not  to  reduce 
it  below  80  or  85,  for  then  it  would  become  in- 
jurious, not  only  by  favoring  dilalation,  but  by 
increasing  the  already  almost  peculiar  tendency 
to  sudden  death.  Digitalis  may  be  given,  but 
with  more  caution  than  in  any  other  valvular 
disease,  and  with  quite  as  much  caution  as  in 


THEIR    DIAGNOSIS    AND    TREATMENT.  61 

dilatation  of  the  left  ventricle.  A  minute  dose 
often  repeated — say  every  fifteen  minutes — is  in- 
finitely safer  than  a  larger  dose  at  correspond- 
ingly long  intervals  ;  a  half  a  drop  of  the  fluid 
extract  every  ten  or  fifteen  minutes  will  often  be 
found  sufficient  to  keep  the  pulse  at  85,  when 
without  it,  it  would  ascend  to  100  or  110. 

c.  I  am  in  the  habit  of  giving,  empirically,  in 
every  affection  of  the  heart,  where  there  is  un- 
easiness, pain  or  much  discomfort,  a  fourth  of  a 
grain  of  quinine,  with  the  sixteenth  or  thirty- 
second  part  of  a  grain  of  opium  from  three  to 
six  times  a  day.  I  double  or  quadruple  the  dose 
at  times,  when  there  is  renal,  pleuritic  or  hepa- 
tic pain,  and  patients  more  frequently  ask  for  a 
repetition  of  this  remedy  than  of  any  other  ;  but 
if  there  is  headache,  which  is  of  frequent  occur- 
rence in  valvular  diseases,  the  smallest  dose  of 
opium  appears  to  make  it  worse,  while  small 
doses,  one  fourth  or  one-half  grain  of  quinine, 
often  repeated,  gives  prompt  and  steady  relief. 

The  weight  of  the  patient  must  be  reduced  from 
time  to  time  by  diminished  diet,  such  as  lean 
meat  and  dried  meats,  with  a  little  stale  bread, 
in  small  quantities,  without  vegetables  or  liquid 
food.  Even  water  should  be  drank  sparingly. 
By  these  means  the  blood  may  be  diminished  in 


62  DISEASES   OF   THE    HEART  : 

quantity,  pari  pasu,  with  the  decreasing  weight 
of  the  body,  and  at  the  same  time  its  quality  re- 
main unimpaired. 

It  is  by  no  means  desirable  to  add  any  form  of 
spangemia  to  organic  disease  of  the  heart  ;  and, 
although  reduction  of  the  heart's  work  is  imper- 
ative, it  is  of  the  highest  importance  not  to  re- 
duce its  own  strength  and  tone,  while  attempting 
to  diminish  the  blood,  which  is  at  once  it  susten- 
ance and  its  burden  of  toil. 

The  law  applicable  here  is  applicable  in  every 
organic  disease  of  the  heart,  with  modifications 
suitable  to  each  case  ;  to  wit :  the  heart  must  be 
aided  by  diminishing  the  labor  it  has  to  perform, 
without  diminishing  its  own  proper  vigor  or 
functional  ability. 

5.  .Aortic  obstruction —  constriction  of  aortic 
orifice — is  indicated  by  a  murmur  coincident 
with  the  systole.  The^r^^  and  second  sounds  of 
the  heart  may  remain  unimpaired,  but  as  aortic 
constriction  must  induce  hypertrophy,  we  should 
find  the  impulse  of  the  heart  occupying  a  larger 
space,  and  the  systolic  shock  increased,  but  in 
practice  this  is  not  always  so.    "^  . 


*  If  the  aortic  valves  are  also  incompetent,  the  impulse 
win  always  be  much  increased. 


THEIR   DIAGNOSIS    AND    TREATMENT.  63 

But  it  may  as  well  be  stated  here,  that  there  is 
no  known  pathognomonic  sign  or  signs  of  aortic 
constriction.  Its  existence  may  be  made  out  with 
extreme  probability,  but  never  with  the  absolute 
certainty  of  mitral  or  aortic  regurgitation. 

6.  Nothing  can  be  determined  by  the  pulse  of 
exclusive  significance  ;  it  is  likely  to  be  regular 
in  force  and  rhythm  ;  but  if  the  hypertrophy  of 
the  ventricle  is  pronounced,  it  will  be  hard  and 
and  small,  and  have  a  wiry  feel.  Systemic  dropsy 
is  not  a  concomitant  of  aortic  constriction  ;  cough 
is  not  present,  although  there  must  be  tendency 
to  engorgement  of  the  lungs,  when  the  blood  flow- 
ing into  the  ventricle  from  the  pulmonary  veins, 
encounters,  as  it  must,  an  amount  of  blood  en- 
tirely excessive.  There  may  be  a  slight  cough, 
but  if  it  is  persistent,  and  the  lungs  not  inflamed 
or  tuberculous,  and  if  there  is  no  catarrh,  either 
constriction  or  incompetency  at  the  mitral  orifice 
must  be  suspected  as  a  complication.  A  persistent 
aortic  constriction  entails  (Walsh)  a  dilatation  of 
the  mitral  orifice,  and  hence  the  murmur  of  mitral 
regurgitation  from  insufiiciency,  when  the  mitral 
valve  itself  is  perfectly  sound. 

7.  The  anemic  murmur  is  not  persistent  ;  mur- 
mur from  unevenness  of  the  internal  surface  of  the 
ascending  aorta,  is  heard  louder  farther  up  the 
sternum  than  that  from  constriction  of  the  orifice. 


64  DISEASES   OP   THE   HEART  : 

a,  A  marked  fact  in  constriction  of  aortic 
orifice,  is  that  the  murmur  is  frequently  heard  in 
so  many  places  and  at  such  remote  distances  from 
its  origin.  It  is  heard  under  the  right  clavicle 
near  the  axilla  ;  it  is  heard  in  the  carotid,  in  the 
interscapular  spaces,  in  all  the  intercostal  spaces 
as  low  as  the  sixth,  and  in  nearly  as  many  of  the 
left  interspaces. 

h.  It  is  of  slow  progress  towards  a  fatal  termi- 
nation, and  is  susceptible  of  becoming  null  as  to 
its  injurious  systemic  effects,  by  the  hypertrophy 
of  the  ventricles,  left  and  right.  I  say  left  and 
right,  because  this  is  the  order  in  which  their 
hypertrophy  occurs  in  aortic  constriction. 

8.  JVarroiving  of  the  aorta  is  sometimes  a  con- 
genital condition,  probably  an  intra-uterine  arrest 
of  development.  The  striking  case  mentioned 
by  Latham  exhibited  the  aorta  and  all  its  prin- 
cipal branches  entirely  free  from  disease,  but 
more  than  one-half  less  than  their  natural  capa- 
city ;  the  heart  was  found  enormously  enlarged 
and  its  cavities  dilated.  In  Meckel's  case  (1750) 
quoted  by  Latham,  the  patient  was  a  puny  girl  of 
18.  She  had  been  from  time  to  time  subject  to 
palpitation,  and  anguish,  and  trembling  of  the 
limbs,  from  infancy  to  her  fourteenth  year,  and 
thenceforward  the  palpitation  and  anguish  had 


THEIR    DIAGNOSIS    AND    TREATMENT.  65 

become  constant  and  more  severe  until  her  death. 
Upon  dissection,  the  heart  was  found  enormously 
enlarged,  and  the  aorta,  throughout  its  whole 
course,  especially  through  the -chest  and  all  its 
principal  branches,  marvellously  narrowed.  The 
heart  had  both  its  ventricles  dilated,  and  their 
substance  more  soft  than  natural ;  its  auricles 
also  dilated,  but  the  left  to  a  degree  far  greater 
than  any  other  cavity.  It  was  capable  of  con- 
taining the  enormous  quantity  of  twelve  ounces, 
while  the  corresponding  ventricle  only  contained 
foHr.  The  aorta  was  not  more  than  half  the 
diameter  of  the  pulmonary  artery." 

These  were  evidently  congenital  malformations 
of  the  aorta,  and  the  enlargement  of  the  heart 
was  a  necessary  consequence,  and  perhaps  an  in- 
dispensable  condition  for  the  continuance  of  life. 

But  constriction  of  a  short  segment  of  the 
aorta  will  have  the  same  effect  on  the  heart 
as  this  general  narrowing  of  the  aortic  trunk  and 
its  principal  branches. 

9.  The  treatment  of  aortic  constriction  is  in  no 
wise  peculiar,  and  would  be  the  same,  with  limi- 
tations, as  that  of  aortic  or  mitral  regurgitation. 
When  the  patient  becomes  over  fatigued  or  ex- 
cited, the  pulse  is  very  likely  to  become  oppres- 
sively intermittent,  perhaps  to  the  extent  of  eight 

H 


66  DISEASES    OF   THE    HEART  : 

or  ten  times  a  minute.  When  such  a  condition 
supervenes,  absolute  quiet  should  be  enjoined, 
and  the  heart  stimulated  to  regular  contractions, 
by  a  dose  of  lavender  and  ammonia,  or  by  dry 
cups.  A  little  blood  abstracted  from  the  pre- 
cordia  by  leeches,  or  scarifications  and  cups 
would  almost  instantly  relieve  the  overtasked 
organ,  not  entirely  by  reflex  action,  but  by 
absolutely  diminishing  the  fullness  of  the  ves- 
sels near  the  base  of  the  heart,  for  it  will  be 
borne  in  mind  that  the  internal  mammary  artery 
rests  upon  the  costal  cartilages,  a  short  distance 
from  the  margin  of  the  sternum ;  it  sends 
branches  to  the  upper  part  of  the  pericardium — 
pericardiac  arteries — also  to  the  skin  covering  the 
base  of  the  heart — anterior  perforating  arteries — 
hence  blood  abstracted  from  the  precordia  would 
be  abstracted  from  the  near  vicinity  of  the  heart 
itself — namely,  from  the  membrane  investing  it. 
And  it  is  for  this  anatomical  reason  that  local 
depletion  is  insisted  upon  in  pericarditis  by  a 
late  author  (Markham). 

But  however  this  matter  be  explained,  one 
thing  is  well  known  to  all  observers,  that  the 
local  abstraction  of  blood  in  the  vicinity  of  the 
hearths  valves  rapidly  relieves  all  cases  of  angina 
pectoris  in  the  various  forms  of  unsound  heart. 


THEIR    DIAGNOSIS    AND   TREATMENT.  67 

I  am  not  oblivious  of  an  apparent  discrepancy 
in  this  statement  with  a  fact  previously  stated, 
that  neuralgic  pain,  of  which  angina  pectoris  is 
undoubtedly  an  example,  depends  on  some  local 
anemia.  But  this  is  more  apparant  than  real — 
for  the  anemia  may  [be  relative  or  absolute — 
absolute  when  the  total  mass  is  diminished  ; 
relative  when  there  is  merely  obstruction  to  its 
movement  through  some  part.  Again,  a  structure 
may  be  overwhelmed  with  venous  blood  in  a  state 
of  stasis  ;  for  example,  the  arm  below  a  ligature  ; 
the  brain  and  upper  extremities  from  a  tumor 
pressing  on  the  descending  cava.  In  this  case 
there  would  be  pain  in  the  head,  perhaps,  and 
yet  there  is  excess  of  blood  ;  but  there  is  diminu- 
tion of  arterial  blood  circulating  in  the  obstructed 
parts — this  is  relative  anemia. 

Excess  of  non-oxygenated  blood  is  equivalent 
as  to  the  production  of  pain,  to  diminution  or 
defect  of  arterial  blood — anemia.  The  pain  in- 
duced by  this  venous  stasis  or  retardation,  might 
be  relieved  by  local  depletion,  while  pain  from 
direct  anemia  of  red  blood  should  be  relieved 
by  arterial  stimulants  and  hsematogens.  The 
pain  of  angina  'pectoris  is  probably  often  if  not 
always  caused  by  local  retardation  of  the  blood 
current,  that  is,  by  venous  congestion — relative 
anemia. 


68  DISEASES   OF   THE   HEART  : 

But  it  cannot  be  ignored  that  this  local  deple- 
tion is  much  more  applicable  to  acute  inflamma- 
tions of  the  inside  or  outside  of  the  heart,  espe- 
cially of  the  latter,  than  to  sudden  accessions  of 
congestion  or  anguish  in  chronic  changes  of  the 
heart's  structure,  such  as  the  affection  under  con- 
sideration— constriction  of  the  aortic  orifice.  If 
the  paroxysm  or  excessive  palpitation  in  this 
chronic  affection  of  the  heart,  or  of  most  others 
of  the  same  organ  be  not  promptly  relieved  by 
dry  cups,  sinapisms,  or  by  leeches  or  scarifica- 
tions, the  overtasked  heart  should  be  relieved  by 
a  small  amount  of  blood  taken  from  the  arm. 
This  is  rational  in  theory  and  verified  in  prac- 
tice. *'  I  consider  that  T  have  seen  life  preserved 
by  timely  abstraction  of  blood  (by  venesection) 
in  cases  of  chronic  valvular  diseases  of  the  heart, 
where  the  organ  was  so  overwhelmed  and  labor- 
ing as  to  render  death  imminent.^'     (Markham.) 

10.  Care  must  be  taken  that  too  much  blood, 
relatively  to  the  condition  of  the  patient,  be  not 
taken  from  the  arm,  lest  by  the  alteration  of  the 
normal  ratio  of  globules  and  fibrin,  or  by  the 
feeble  action  induced  in  the  heart,  the  formation 
of  clot  be  favored,  and  death  be  caused  in  an  in- 
stant. Such  accidents  have  occurred,  to  the  hor- 
ror of  the  physician,   who  bled  with   the  most 


THEIR    DIAGNOSIS    AND    TREATMENT.  69 

honest  intentions,  and  under  the  influence  of  the 
dictation  of  the  classic  authors  in  medicine.  But 
under  the  present  rational  ideas  of  the  uses  of 
blood-letting — merely  to  relieve  an  immediate 
and  urgent  necessity — there  is  little  danger  of  a 
careful  physician  allowing  more  blood  to  flow 
than  is  absolutely  requisite  to  relieve  the  con- 
gestion of  the  heart  or  lungs.  Concerning  the 
treatment  of  aortic  constriction  itself,  we  know 
absolutely  nothing.  All  we  can  do  is  to  prevent 
the  accidental  complications  which  attend  it  from 
suddenly  destroying  life. 

11.  Like  all  other  chronic  diseases  of  the  heart, 
it  has  no  known  essential  (denoting  its  essence) 
symptom  ;  and  hence  we  cannot  direct  our  treat- 
ment t(^g^e  cure,  or  the  arrest,  or  even  the  dete- 
rioration of  the  disease  in  its  intimate  nature. 
We  see  not  the  disease,  but  its  effects  ;  namely, 
constriction,  incompetency,  etc.  These  are  the 
anatomical  alterations  which  the  disease  has  pro- 
duced, but  they  are  not  the  disease  itself.  This 
lies  behind  the  visible  effect.  It  exists  anterior 
to  it  in  the  blood,  and  in  the  ultimate  structure 
of  nerve  and  brain  substance. 

In  chronic  affections  of  this  kind,  then,  we  can 
only  treat  symptoms.  But  what  are  symptoms  ? 
Latham  has  eloquently  and  well  said,  *'  They  are 


70  DISEASES     OF   THE   HEART  : 

not  mere  signs  of  the  disease,  but  they  are  direct 
emanations  from  it  ;  not  things  in  themselves 
nugatory,  but  eminently  real.  They  are  natural 
sensations  unduly  exalted,  or  unduly  depressed, 
or  variously  changed  or  perverted.  They  are 
natural  functions  hurt,  hindered  or  abolished. 
So  that  a  man  may  often  with  stricter  propriety 
be  said  to  be  ill  of  his  symptoms  than  to  be  ill  of 
his  disease,  and,  what  is  more,  to  die  of  his  symp- 
toms than  to  die  of  his  disease. 

Accordingly,  it  often  happens,  even  where  the 
disease  is  best  understood,  that  we  treat  the 
symptoms  of  the  disease  only,  just  as  if  we  had 
no  knowledge  of  anything  beyond  them.  There- 
fore, when  we  have  confessedly  no  strict  knowl- 
edge beyond  them,  (which  is  the  case  ipi  chronic 
aflfections  of  the  heart,)  and  the  aim  of  our  prac- 
tice must  need  centre  in  the  symptoms;  we  are 
not  to  lament  over  the  shortcomings  of  our  art, 
and  its  straitened  capacity  for  doing  good  ;  for, 
it  does  not  follow  that,  if  we  knew  the  disease 
ever  so  well,  we  would  treat  it  otherwise  than  we 
are  now  treating  its  symptoms,  or  that  what  we 
are  now  doing  for  the  symptoms  would  not  be 
the  best  and  would  not  be  all  that  could  be  done 
for  the  disease  itself." 

Aortic  regurgitation  cannot  he  mistaken  for  aor- 


THEIR    DIAGNOSIS   AND   TREATMENT.  71 

tic  constriction  or  obstruction.  In  the  former  case, 
the  murmur  is  coincident  with  second  sound — of 
the  pulmonary  artery,  when  that  of  the  aorta  is 
replaced  by  the  murmur — in  the  latter  case,  the 
murmur  is  synchronous  with  the  first  sound,  and 
both  first  and  second  sounds  are  audible.  It  is 
more  common  in  old  people,  but  young  people 
are  by  no  means  exempt  from  it. 

Were  I  called  upon  for  an  opinion  in  a  sus- 
pected case  of  this  kind,  I  should  attempt  a  diag- 
nosis by  .exclusion.  It  could  be  determined  that 
the  murmur  was  not  mitral  regurgitation  from 
its  location  and  direction,  and  from  the  persist- 
ence of  mitral^r^^  sound,  if  the  mitral  orifice  were 
not  also  incompetent.  It  is  not  aneurismal  from 
the  absence  of  dysphagia,  of  sense  of  a  foreign 
body  in  the  thorax,  of  thrill  on  digital  pressure 
in  the  intercostal  spaces.  It  is  not  aortic  regur- 
gitant, for  it  is  not  coincident  with  the  diastole, 
etc.,  etc. 

I^  must  not  leave  the  consideration  of  alter- 
ations of  the  aortic  orifice,  without  alluding  to  an 
unexplained  fact  in  connection  with  aortic  regur- 
gitation ;  that  is,  extreme  tendency  to  instanta" 
neous  death. 

The  patient  drops  dead  without  the  slightest 
premonition,  and    probably  without  any  excita 


72  DISEASES    OF   THE   HEART  : 

tion  of  the  circulation,  as  well  as  when  walking 
or  when  motionally  excited.  The  freer  the  heart 
is  from  any  other  lesion,  Walshe  says,  the  more 
likely  is  the  patient  to  instant  death  from  aortic 
regurgitation.  The- assurance  of  life  is  much 
longer  if  to  the  aortic,  mitral  regurgitation  and 
ventricular  hypertrophy  ,be  added.  Even  the 
addition  of  that  most  fatal  of  all  valvular  affec- 
tions tricuspid  insufficiency^  is  preferable  to  aortic 
regurgitation,  pure  and  simple. 

The   instant  death   can  be   guarde^against, 

theoretically,  by  seeing  that  blood  be  noFmade  in 

excess,  in  fact  that  it  be  abstracted  from  the  re- 

'  gion  of  the  heart   from  time  to  time,  if  there  is 

the  least  evidence  of  labored  circulation. 

Death  occurs  from  syncope.  It  is  a  "  fainting 
away''  from  which  the  patient  never  awakes. 
This  peculiar  tendency  in  aortic  regurgitation 
was  first  publicly  noticed  by  Chomel,  and  next 
by  Aran.     (Walshe.) 

I  have  condensed  the  following  additional  ob- 
servations on  this  subject  from  the  Gazette  des 
HopitauXj  9th  June,  1860. 

"  In  1844,  M.  H.,  Minister  of  Finance  under  the 
reign  of  Louis  Phillipe,  was  working  one  morning 
with  one  of  the  ministry.  The  absence  of  a  docu- 
ment compelled  the  latter  to  absent  himself  for 


THEIR   DIAGNOSIS   AND   TREATMENT.  73 

a  few  moments.  When  he  returned,  five  minutes 
or  more  after  his  departure,  he  found  th€  minister 
with  his  body  inclined  backwards  over  his  chair, 
his  right  arm  hanging  over  the  arm  of  the  chair, 
still  holding  the  pen  with  which  he  had  designed 
to  write  his  signature  to  the  document.  All  the 
means  employed  in  such  cases  were  resorted  to 
in  order  to  restore  M.  H.  to  life,  but  in  vain  ;  he 
was  dead. 

The  autopsy,  made  by  Blandin,  revealed  no 
lesion  either  in  the  brain  or  lungs.  The  heart 
was  very  large  and  loaded  with  fat  ;  its  right 
cavities,  distended  with  black  blood,  were  a  little 
dilated  and  very  much  thinned.  The  left  ven- 
tricle was  greatly  hypertropied  and  enormously 
dilated.  Excepting  a  few  nodosities,  the  mitral 
valve  was  healthy  ;  but  the  aortic  orifice  was 
much  constricted,  and  the  sigmoid  valves  entirely 
ossified.  There  were  a  few  cretacious  deposits  in 
the  aorta. 

It  is  important  to  add  that  the  health  of  M. 
H,  had  exhibited  no  grave  derang^ement  which 
could  have  presaged  the  sudden  stroke  which 
teiininated  his  existence.  He  had  never  had  any 
of  the  general  symptoms  pertaining  to  diseases 
of  the  heart, 

''Thirteen  years  after,  in  1857,  Mauriac,  fre- 

I 


74  DISEASES   OP   THE   HEART  : 

quently  saw  at  La  Pitie,  a  sub-officer  of  the  guard 
of  Paris,  who  had  long  frequented  the  hospital 
for  advice  concerning  palpitation  of  the  heart, 
and  a  constant  difficulty  of  respiration.  In  this 
case  there  was  ascertained  to  be  a  double  hruit 
de  souffle  at  the  base  of  the  heart,  and  the  diag- 
nosis was  aortic  insufficiency.  He  had  neither 
dropsy  nor  anasarca.  For  many  months  M. 
Mauriac  did  not  see  this  patient,  when  he  learned 
that  he  had  died  suddenly.  One  of  his  comrades, 
who  was  on  duty  with  him,  left  him  alone  to  copy 
some  document  ;  when  he  returned,  at  the  expi- 
ration of  a  few  moments,  he  found  his  friend  dead 
in  front  of  his  desk.  At  the  autopsy,  no  lesion 
was  found  anywhere,  except  insufficiency  of  the 
valves  of  the  aorta,  with  hypertrophy  and  dilata- 
tion of  the  left  ventricle  of  the  heart. 

One  year  after  this,  Mauriac  observed  the  fol- 
lowing case  :  A  young  man,  twenty-six  years  old, 
of  robust  constitution,  about  five  months  before 
entering  into  the  hospital,  had  suffered  for  a  fort- 
night with  pains  under  the  left  false  ribs.  Six 
weeks  before;*  he  had  palpitation  for  the  first 
time,  and  one  month  previous,  that  is,  on  the  3d 
of  March,  he  was  taken  with  obstructed  or  im- 
peded respiration  and  pains  in  the  left  groin, 
which  radiated  along  the  lower  extremity  of  the 
same  side.     The*  2d  of  April,  his  condition  was 


TJ^Em    DIAGNOSIS    AND    TREATMENT.  75 

as  follows  :  Slight  emaciation  :  partial  distension 
T3f  the  veins  of  the  neck;  visible  arterial  pulsa- 
tions ;  skin  warm  and  moist  ;  88  to  92  pulsations, 
vibrating,  irregular,  intermittent  at  the  arterial 
diastole  from  time  to  time.  The  heart  is  consid- 
erably enlarged.  The  maximum  of  impulsion 
takes  place  in  the  fifth  intercostal  space,  11  centi- 
meters ^  from  the  axis  of  the  sternum  ;  it  mea- 
sures vertically  11  centimeters  upon  the  median 
line,  and  more  than  IC  centimeters  obliquely 
from  right  to  left.  The  impulsion  is  thrilling, 
and  accelerated  at  times,  as  if  the  heart  struggled 
to  overcome  an  obstacle.  The  ear  applied  over  the 
apex,  perceives  a  double  bruit  de  souffle,  the* second 
much  softer,  more  mellow  and  prolonged  than 
the  first.  Ascending  towards  the  base  of  the 
heart,  this  double  stethoscopic  phenomenon  per- 
sists and  seems  to  reach  its  maximum  of  in- 
tensity under  the  second  and  third  intercostal 
spaces,  on  the  left  side,  in  the  vicinity  of  the 
sternum,  also  under  the  corresponding  portion  of 
this  bone.  This  double  bellows-murmur  is  also 
very  marked  in  the  aorta,  the  dullness  of  which 
is  sensibly  increased.  Finally,  in  whatever 
place   the   ear  is   applied,   there    is  not  heard 


*  A  centimeter  is  four-tenths  of  an  inch  nearly  ;  a  milli- 
meter is  .0S9  inch. 


76  DISEASES    OF   THE  HEART  : 

any  trace  of  the  second  normal  beat  of  the  heart. 
Bellows-murmur  diastolic,  intermittent,  and  very 
strong  in  the  carotids.  There  is  neither  fever 
nor  oedematous  swelling  of  the  abdominal  ex- 
tremities. 

The  8th  of  April,  the  6th  day  after  his  entrance 
into  the. hospital,  the  patient  died  suddenly,  at 
seven  o'clock  in  the  morning.  During  the  last 
few  days  of  his  life  he  complained  of  a  feeling  of 
severe  oppression  and  a  sensation  of  uneasiness 
at  the  epigastrum  ;  the  morning  of  the  day  before 
his  death,  he  complained  of  great  difiSculty  of 
respiration  ;  however,  he  still  kept  about  ;  in 
the  evening  he  supped  as  usual ;  during  the  night 
he  had  some  suffocating  attacks,  his  sleep  was 
agitated  and  painful  •  at  seven  o'clock  in  the 
morning  he  awoke  and  lay  tranquilly  in  bed. 
All  at  once  he  lost  all  consciousness,  his  head  fell 
back,  his  limbs  straightened  and  were  convul- 
sively agitated,  his  face  became  rapidly  purple, 
and  almost  immediately  grew  pale,  and  in  less 
than  ten  minutes  he  died. 

The  heart,  emptied  of  its  clots,  measures  0.13 
centimeters  from  base  to  point,  also  transversely 
at  the  level  of  the  base.  The  pulmonary  orifice 
was  0.075  millimeters  in  circumference.  The 
ventricle  is  a  little  dilated   and   hypcrtropied. 


THEIR    DIAGNOSIS    AND    TREATMENT.  77 

The  right  auriculo-ventricular  orifice  is  somewhat 
enlarged  ;  its  valves  are  supple  and  transparent  ; 
the  left  presents  some  granulations  on  the  auri 
cular  surface.  Very  marked  dilatation  of  the 
right  auricle. 

The  aorta  is  dilated  immediately  after  its  issue 
from  the  heart  in  such  a  manner  as  to  assume  a 
position  more  anterior  than  usual,  and  crowd  the 
pulmonary  artery  backwards;  the  dilation  ex- 
tends as  high  as  the  origin  of  the  left  subclavian  ; 
it  has,  however,  preserved  the  flexibility  of  its 
walls  ;  finally,  in  the  neighborhood  of  its  orifice 
it  exhibits  a  beginning  of  atheromatous  altera- 
tion. The  left  ventricle  is  enormously  dilated. 
The  dilatation  affects  solely  the  arterial  portion, 
and  the  mitral  valve  is  forcibly  pushed  back- 
wards, also  the  fleshy  columns  inserted  into  it, 
which  latter  are  atrophied  rather  than  hyper- 
tropied.  The  diameter  of  this  ventricle  is  7 
centimeters,  the  thickness  of  its  walls  13  milli- 
meters. The  mitral  valve  is  supple,  but  the  ten- 
dons which  subtend  it  are  thickened.  Insuffi- 
ciency of  the  sigmoid  valves  of  the  orifice  of  the 
aorta.  A  clot  is  prolonged  to  a  height  of  52 
millimeters  above  the  origin  of  the  vessel,  and 
adheres  to  the  greatly  altered  right  valve.  The 
anterior  and  posterior  sigmoid  valves  are  thick- 


78  DISEASES   OP   THE    HEART  t 

ened  and  indurated,  and  have  lost  their  elasticity, 
and  contain,  particularly  at  their  bases,  cretace-  - 
ous  and  cartilaginous  granules  ;  their  separating 
partition  is  much  thickened.     The  right  valve  is 
almost  entirely  destroyed  at  its  middle. 

Dr.  Mauriac  proceeds  to  investigate  the  mech- 
anism of  sudden  death,  to  study  the  elements  of 
prognosis,  and  the  therapeutical  indications  to  be 
deduced  from  a  knowledge  of  this  mechanism. 

When  there  exists,  says  M.  Mauriac,  an  insulfi* 
ciency  of  the  sigmoid  valves  of  the  aorta,  and 
when  the  hiatus  which  is  the  consequence  of  this 
is  insufficiently  large  to  permit  the  re-entrance 
of  a  considerable  quantity  of  blood,  at  the  instant 
of  the  hearths  diastole,  into  the  interior  of  the 
left  ventricle,  the  latter  becomes  more  or  less 
distended,  and  it  is  compelled  to  increase  its  ac- 
tivity to  impel  into  the  whole  arterial  system 
this  excess  of  blood,  added  to  the  amount  which 
comes  from  the  lungs.  There  results  a  hyper- 
trophy of  the  walls  and  a  dilatation  of  the  cavity 
of  this  ventricle. 

So  long  as  these  lesions  do  not  go  beyond  a 
certain  point,  and  particularly  so  long  as  they 
remain  simple,  that  is  to  say,  not  complicated 
with  any  other  morbid  change,  they  oppose  the 
stagnation  of  the  blood  in  the  lungs  and  in  the 


THEIR.   DIAGNOSIS    AND    TREATMENT.  79 

cardiac  cavities ;  and  are,  therefore,  salutary 
because  they  prevent  the  insufficiency  from  pro- 
ducing any  considerable  perturbation  in  the  equi- 
librium of  the  general  and  pulmonary  circulation. 
But  hypertrophy  and  dilatation  of  the  left  ven- 
tricle of  the  heart,  consecutive  to  valvular  insuffi- 
ciency, tend  almost  always  to  indefinite  increase ; 
and  in  proportion  as  they  increase  they  lose 
more  and  more  the  character  of  a,  so  to  speak, 
normal  and  physiological  hypertrophy  and  dila- 
tation, because  they  become  the  seat  of  vsecondarj 
lesions,  which  embarrasses  the  circulation  in  the 
hearths  own  vessels  and  alter  its  muscular  fibre. 

Nevertheless,  when  the  hiatus  of  insufficiency 
is  small,  when  there  is  not  considerable  stricture 
of  the  aortic  orifice,  or  complete  rigidity  of  the 
aortic  valves  ;  when  the  inflammatory  morbid 
process  which  has  produced  the  insufficiency  and 
the  lesions  at  the  origin  of  the  aorta,  is  arrested 
and  definitively  extinguished,  it  is  possible  that 
the  hypertrophy  of  the  left  ventricle  having 
reached  that  degree  which  the  maintenance  of 
the  equilibrium  of  the  circulation  requires,  will 
desist  in  its  progressive  development  and  remain 
stationary  during  the  remainder  of  life.  M. 
Mauriac  considersit  certain  that  such  a  condition 
exists  in  those  individuals  who  have  been  for  a 
long  time  aflfected  with  aortic  insufficiency,  and 


80  DISEASES   OF   THE   HEART  : 

who  finally  suffer  only  slight  inconveniences  re- 
ferable to  the  heart,  such  as  palpitations  or  mo- 
mentary dyspnoea,  etc.  He  has  seen  cases  in 
which  auscultation  left  no  doubt  of  the  existence 
of  an  insuflSciency  of  the  aortic  semilunar  valves, 
who  had  not  even  supposed  they  had  any  disease 
of  the  heart ;  percussion  in  tliese  cases  revealed 
only  slight  enlargement  of  the  heart.  The  hyper- 
trophic process  had  no  doubt  subsided,  and  to 
this  cause  they  were  indebted  for  their  undis- 
turbed health. 

Unfortunately,  hypertrophy  and  dilatation  of 
the  left  ventricle  rarely  remains  circumscribed 
within  these  limits.  There  are  many  causes  which 
tend  constantly  to  augment  these  two  lesions  in 
which  consists  all  the  danger  of  insufficiency,  and 
the  action  of  which  culminates  in  perturbations 
of  the  hearths  own  circulation. 

The  organo-pathological  development  of  hyper- 
trophy and  dilatation  of  the  left  ventricle,  con- 
secutive to  sigmoid  insufficiency,  presents  three 
stages  :  one  stage  of  simple  and  salutary  hyper- 
trophy and  dilation  which  augments  the  labor  of 
the  heart,  and  may  counteract  in  part  for  the  in- 
jurious' effects  of  the  valvular  alterations  ;  a  stage 
of  hypertrophy  and  dilatation  complicated  with 
the  preceding  lesions,  and  with  more  or  less  fatty 


THEIR    DIAGNOSIS    AND   TREATMENT.  81 

degeneresceiice.  Fatty  degenerescence  is  very 
frequent  in  aortic  insufficiency  ;  it  is  the  last  step 
of  morbid  organization  of  which  the  ventricular 
walls  become  the  seat,  when  hypertrophy  and 
dilatation  are  not  arrested  in  their  first  stage. 
Among  the  numerous  causes  of  this  complication, 
M.  Mauriac  thinks  that  which  plays  the  greatest 
part  is  the  progressive  enfeeblement  of  the  inter- 
stitial circulation  of  the  heart,  either  when  this 
enfeeblement  depends  upon  aortic  insufficiency 
itself,  or,  at  the  same  time,  upon  alterations  in 
the  origin  of  the  aorta  and  cardiac  arteries. 
Still,  as  these  alteration?  run  a  course  essentially 
chronic,  as  well  as  the  valvular  lesions,  it  results 
that  it  is  only  at  a  very  advanced  period  of  car- 
diac disease  that  degenerescence  is  observed. 

When  it  has  invaded  the  whole  organ,  there  is 
observed  a  considerable  thinning  of  the  walls, 
dilatation  and  extreme  flaccidity.  Hypertrophy 
of  the  walls  is,  then,  in  this  phase  of  the  malady 
replaced  by  their  atrophy  ;  but  the  dilatation 
persists  and  tends  even  to  become  increased,  if 
death  does  not  intervene  and  suddenly  remove 
the  patient.  • 

Hence,  we  arrive  at  the  conclusion  that  the 
organic  cause  which  induces  sudden  death  in  cases  of 
aortic  insufficiency^  is  hypertrophy  and  dilatation  of 

J 


82  DISEASES    OF   THE    HEART  : 

the  left  ventricle,   complicated    with   congestion   or 
degenerescence  of  the  heart, 

4* 

From  the  instant  these  lesions  have  taken  place, 
the  patient  is  momentarily  in  danger  of  sudden 
death.  Finally,  this  mode  of  the  termination  of 
life  never  occurs  in  those  cases  that,  consecutively 
to  innoclusion  of  the  aortic  valves,  have  only 
moderate  dilatation  and  hypertrophy.  All  the 
observations  collected  by  M.  Mauriac  prove  this 
fact  in  a  categoric  manner. 

These  premises  admitted,  he  explains  the  me- 
chanism of  sudden  death. 

The  heart,  the  centre  of  sympathy,  upon  which 
are  accumulated,  by  reflex  movement,  all  the 
impressions  of  the  organism,  whether  morbid  or 
physiological,  becomes,  in  consequence  of  the 
lesions  suffered,  excessively  susceptible  to  the 
perception  of  these  impressions.  Thus,  every 
moral  perturbation,  every  affection  of  the  mind, 
which  disturbs  or  tires  the  centres  of  innervation, 
all  fatigue  proceeding  from  excessive  muscular 
exercise,  or  from  whatever  expense  of  nervous 
influx,  are  so  many  eausQs  which  may  accident- 
ally induce  *death. 

Under  the  influences  of  any  of  these  causes,  the 
ventricular  systole  is  enfeebled,  becomes  incom- 
plete, drives  into  the  arterial  system  only  a  por- 


THEin    DIAGNOSIS    AND    TREATMENT.  83 

tion  of  the  blood  which  was  accumulated  in  the 
ventricular  cavity,  at  the  moment  ot  the  diastole. 
But  the  elasticity  and  contractility  of  the  aorta 
and  its  branches  not  being  duninished,  it  re-acts 
upon  the  blood-columns,  and  impels  a  recurrent 
jet  through  the  hiatus  of  insufficiency  with  the 
same  energy  as  previously. 

It  follows  that,  after  the  second  systole,  the 
heart  is  overcharged  with  a  mass  of  blood  ex- 
ceeding the  amount  it  contained  at  the  instant  it 
was  surprised  with  the  debilitating  action  of  the 
accidental  cause.  If  it  recover  its  energy,  the 
circulating  equilibrium  may  be  restored  ;  but  if 
its  feebleness  continue,  the  difficulty  increases, 
and  the  quantity  of  blood  which  accumulates  in 
its  cavity  is  augmented  at  each  systole,  and  at 
each  reaction  of  the  aorta  upon  the  liquid  column 
which  is  no  longer  shut  off  from  the  heart  by  the 
complete  partition  which  is  made  in  the  normal 
state  by  the  aortic  volves. 

The  accumulation  in  the  ventricular  cavity  of 
the  blood  which  comes  from  the  lungs  and  the 
different  arteries,  dilates  the  left  ventricle  more 
and  more  ;  and,  finally,  it  can  no  more  contract. 

From  all  that  precedes,  it  follows,  that  as  to 
the  prognosis,  that  of  all  the  diseases  of  the  hearts 
there  is  none  the  result  of  which  is  so  difficult  to 


84  DISEASES    OF   THE    HEART  : 

be  foreseen,  or  that  exposes  the  physician  to  more 
deception  and  risk  of  mistake. 

Here  are  a  few  signs  which  may  enlighten  him 
upon  the  gravity  and  result  of  the  affection  :         ^ 

Shock  of  the  point  of  the  heart  several  times 
the  thickness  of  a  finger  outside  of  a  line  vertical 
with  the  left  nipple,  energy  of  its  impulse,  ab- 
sence of  normal  resonance  over  a  considerable 
extent,  indicating  that  the  hypertrophy  and  dila- 
tation of  the  left  ventricle  have  reached  that  de- 
gree where  sudden  death  by  instant  cessation  of 
the  movements  of  the  heart  becomes  imminent ; 
all  these  are  signs  of  the  worst  significance. 

In  general,  only  uncertain  inferences  as  to  the 
result  can  be  drawn  from  abnormal  murmurs. 

The  depressihility  of  the  pulse,  which  is  observed 
at  its  highest  degree  when  the  hiatus  of  insufiS- 
ciency  is  very  large,  should  be  regarded  as  a  sign 
of  bad  import.  Among  functional  troubles,  ac- 
cessions of  dyspnoea,  above  all^  when  accompa- 
nied with  violent  palpitations,  are  also  of  serious 
significance ;  it  is  the  same  with  syncope,  which, 
extremely  grave  in  all  affections  of  the  heart, 
without  exception,  is  much  more  so  in  aortic 
insufficiency  than  in  any  other  disease  of  the 
organ. 


I  THEIR    DIAGNOSIS   AND   TREATMENT.  85 

The  resources  of  science  are,  unfortunately,  too 
often  powerless  in  this  affection.  All  the  efforts 
of  the  physician  should  be  directed  against  the 
most  imminent  danger,  that  of  syncope,  by  all  the 
hyt^ienic  means  susceptible  of  detaining  in  its 
progress  the  evolution  of  the  organic  lesions. 
The  facts  demonstrate  the  danger  of  the  method 
of  Valsalva,  of  which  indications  have  been 
imagined  to  exist  in  the  fullness  and  apparent 
force  of  the  arterial  diastoles.  Bleeding  should 
be  practiced  only  with  very  great  moderation, 
and  only  in  cases  where  there  exists  an  engorge- 
ment of  the  lungs  which  impedes  the  general  cir- 
culation. 

Sedatives  and  cardiaco-vascular  hyposthenisants 
are  indicated  as  palliatives  in  all  cases  where 
there  are  violent  palpitations,  dyspnoea,  or  pre- 
cordial anxiety.  Finally,  the  true  curative  indi- 
cations are  deduced  from  the  course  of  the  morbid 
process,  of  which  the  walls  of  the  heart  are  the 
seat  ;  it  is  especially  by  revulsive  treatment, 
(cupping,  scarifications,  temporary  blisters,  cau- 
teries, etc..)  that  the  indications  of  treatment  are 
fulfilled. 


86  DISEASES    OF   THE   HEART  t  » 

CHAPTER  Y. 

Valves  op  the  Pulmonaky  Aktery.  Constriction  of 
THE  Mitral  Orifice.  Constriction  of  the  Right 
AuRicuLO- Ventricular  Orifice. 

1.  Skoda  says  he  has  never  observed  deficiency 
of  the  valves  of  the  pulmonary  artery,  or  constric- 
tion of  its  orifice^  in  consequence  of  faulty  valves, 
[By  '*  faulty'^  he  means  diseased  or  altered,  but 
not  defective  or  incompetent.]  Should  incom- 
petent pulmonic  valves  occur,  the  incompetency 
would  be  certainly  recognized  by  a  murmur  in 
place  of  the  second  sound,  of  the  pulmonary 
artery,  and  this  murmur  would  be  heard  loudest 
between  second  and  third  ribs,  near  sternum  left 
side,  and  from  that  point  directly  dow^nwards. 
There  would  be  hypertrophy  and  dilatation  of 
the  left  ventricle  in  a  less  marked  degree  than  in 
aortic  regurgitation,  and  hence  the  impulse  of 
the  heart  would  be  felt  over  a  less  extent  than  in 
the  latter  affection.  The  murmur  of  pulmonic 
regurgitation  has  a  sighing  quality,  (Hope)  not 
observed  in  aortic  regurgitation.  This  sighing 
murmur  is  also  heard  in  connection  with  dimin- 
ished second  pulmonic  sound,  when  the  valves  of 
the  pulmonary  artery  are  slightly  defective,  but 
not  so  much  so  as  to  prevent  the  flapping  of  the 
valves.     (Hope's  experiment.) 


THEIR    DIAGNOSIS    AND    TREATMENT.  87 

2.  The  pulmonic  valves  are  also  liable  to  be- 
come roughened,  in  a  chronic  manner,  from  exu- 
dation of  plastic  matter,  or  from  the  deposition 
of  analogous  tissue,  without  destroying  their 
competency.  In  such  case  there  would  be  a 
murmur  synchronous  with  the  systole,  heard 
loudest  in  second  left  interspace,  and  propa- 
gated directly  upwards. 

3.  Hope  never  saw  or  found  recorded  a  case  of 
pulmonic  regurgitation  from  disease  of  the  pul- 
monary valves.  He  created  the  murmur  artifi- 
cially in  the  heart  of  an  ass  poisoned  with  woo- 
rara. 

4.  The  slightest  compression,  as  of  a  tumor, 
a  congested  portion  of  lung,  a  foreign  body  upon 
the  pulmonic  artery  or  aorta,  produces  murmur 
and  thrill  synchronous  with  the  hearths  systole. 

5.  The  second  sound,  much  diminished,  might 
be  heard  in  many  places  on  the  chest,  even  were 
the  pulmonic  valves  utterly  incompetent,  if  those 
of  the  aorta  were  still  sound  ;  but  the  second  souna 
heard  would  proceed  from  the  aortic,  not  the  pul- 
monary valves  ;  and  so,  when  the  aortic  valves 
are  incompetent,  so  as  to  furnish  no  sound,  a 
much  diminished  second  sound  will  quite  pro- 
bably be  heard  in  the  second  left  interspace,  pro- 
ceeding from  the  sound  pulmonic  valves  ;  for  the 


88  DISEASES    OF   THE    HEART  : 

second  sound  is  caused  by  the  shutting  back,  at  the 
same  instant,  of  both  sets  of  sigmoid  valves,  just 
as  the  first  sound  results  from  the  synchronous 
closing  of  right  and  left  auriculo-ventricular 
valves.  Practically,  lesions  of  the  pulmonic  valves 
may  he  ignored  in  the  diagnosis  of  unsound  heart, 

6.  Constriction  of  the  mitral  orifice.  Diastolic 
murmur  from  this  cause  is  exceedingly  rare,  even 
when  the  constriction  is  considerable  ;  this  defect 
of  murmur  results  from  the  feeble  force  with 
which  the  blood  flows  from  the  left  auricle  into 
the  left  ventricle.  The  auricle  is  a  feeble  muscle, 
and  not  being  supported  by  a  valve,  could  hardly 
inject  the  blood  flowing  into  it  from  the  pulmonary 
veins  into  the  ventricle,  with  force  sufficient 
to  develope  a  murmur,  unless  the  constriction 
should  not  have  a  very  small  orifice,  and  even  then 
the  murmur  must  be  feeble,  and  would  certainly 
be  preceded  by  a  loud  murmur  of  mitral  regur- 
gitation. 

7.  Mitral  diastolic  murmur  is  certainly  very 
rare.  Latham  says  it  is  a  clinical  curiosity  ;  there 
is  no  murmur  because  there  is  no  impelling  force 
from  behind.  Markham  met  with  less  than  a 
dozen  cases  in  eight  or  nine  years,  a,  Austin 
Flint,  on  the  contrary,  seems  to  have  been  pecu- 
liarly fortunate  in  detecting   this  murmur  ;  he 


THEIR    DIAGNOSIS    AND    TREATMENT.  89 

says  :  *'  It  [mitral  direct  murmur]  is  by  no  means 
so  rare  as  has  been  supposed.  I  saw  at  one  time 
last  winter  six  cases  of  it  in  Belle  Vue  Hospital) 
and  several  others  at  Blackwell  Island  Hospital.'^ 

h.  I  have  never  yet  been  able  to  detect  mitral 
direct  murmur,  although  I  have  had  many  cases 
in  which  there  could  scarcely  be  a  doubt  of 
mitral  constriction. 

8.  Sometimes  the  murmur  is  attended  with  a 
palpable  thrill  at  the  left  2^^(ix—fremissement 
cataire;  in  well  marked  cases  where  the  action  is 
vigorous,  a  loud  and  prolonged  murmur  is  heard 
at  apex  and  upwards,  in  direction  of  left  nipple. 
This  affection  causes  hypertrophy  of  left  auricle 
and  right  ventricle,  pulmonary  congestions;  aortic 
sounds  and  beat  of  arteries,  weak  in  proportion 
to  constriction  ;  hasmoptysis  of  venous  blood  fre- 
quent and  easily  excited  ;  breathlessness  easily 
induced  by  over-exertion  ;  rest  and  quiet  in  an 
especial  manner  produce  ease  and  comfort. 
Skoda^s  symptom,  increased  second  sound  of 
pulmonary  artery,  is  here  well  marked,  and  rela- 
tively intensified  on  account  of  the  weakness  of 
the  Ze/if  ventricular  systole  and  diminished  second 
sound  of  aortic  valves. 

9.  Walshe  has  never  heard  this  murmur  of 
great  intensity,  nor  high  in  pitch  ;  it  is,  however, 


90  DISEASES   OF    THE    HEART  : 

sometimes  prolonged.  The  murmur  is  sometimes 
wanting,  where  the  constriction  is  found  after 
death.  The  absence  of  the  murmur  may  be 
reasonably  attributed  to  weakness  of  auricular 
systole,  or  to  smoothness  of  constricted  orifice. 
The  murmur  comeS  and  goes  even  wlien  orifice  is 
greatly  contracted  :  this  is  probably  due  to  vary- 
ing force  of  heart's  action. 

10.  Skoda  says,  in  mitral  constriction  hyper- 
trophy occurs  rapidly  ;  that  it  is  attended  with  a 
prolonged  murmur,  extending  even  into  the  period 
of  the  systole  of  the  ventricle.  During  systole 
no  sound,  or  an  indeterminate  sound,  in  heard  in 
left  ventricle  ;  again,  a  murmur  (systolic)  may 
he  heard  there,  because  deficiency  of  the  mitral 
valves  is  generally  associated  with  constriction 
of  mitral  orifice.  Sounds  of  aorta  weak,  heart's 
impulse  increased  and  perceptible  even,  over  a 
greater  extent  than  natural. 

11.  Hope  says  the  murmur  is  feeble,  soft,  usually 
on  a  lower  key  than  a  whispered  who;  absent 
unless  the  contraction  is  considerable  ;  absent 
also  when  the  contraction  is  greats  providing  the 
current  is  perternaturally  weakened  by  softening, 
or  extreme  dilatation  of  heart,  or  by  both.  In 
such  cases,  there  is  almost  invariably  murmur  of 
regurgitation  ;  hence  the  disease  of  the  valves 


THEIR   DIAGNOSIS    AND    TREATMENT.  91 

would  not  be  overlooked.  This  murmur  is  ex- 
ceedingly rare,  originally  thought  frequent  by 
confounding  it  with  a  murmur  of  regurgitation. 
'•'  I  have  never  known  purring  tremor  accompany 
a  diastolic  mitral  murmur,  the  current  being  too 
feeble  to  produce  it.'^  When  contraction  is  great, 
pulse  is  more  or  less  small,  weak,  intermittent, 
irregular  and  unequal,  in  consequence  of  the 
supply  of  blood  to  left  ventricle  being  insufficient 
and  irregular.  0.  J.  B.  Williams,  quoted  by 
Hope,  says  :  "  When  there  is  contraction  of  the 
mitral  orifice,  there  is  usually  more  hypertrophy 
than  dilatation  in  the  left  ventricle." 

12.  In  this  last  quotation,  there  must  be  perfect 
accord  among  all  thinkers.  Also  in  the  dilata- 
tion with  hypertrophy  of  the  left  auricle  and 
right  ventricle,  but  the  discrepancies  concerning 
the  thrill— fremissement  cataire —  from  mitral  dis- 
ease, are  seemingly  irreconcilable.  Markham 
says,  it  is  frequent.  Corvisart  says,  it  is  "  sensi- 
ble a  la  main  appliquie  sur  la  region  precordialeJ^ 
Hamernik  says,  it  is  like  the  hum  of  a  spinning- 
wheel.  Skoda  says  that  in  certain  cases  vibra- 
tions are  felt  when  the  hand  is  laid  on  the  pre- 
cordial region — the  fremissement  cataire  of  Laen- 
nec. 

1 3.  Hope  never  heard  or  felt  it,  and  does  not  be- 


92  DISEASES    OF   THE   HEART  : 

lieve  it  occurs  as  a  consequence  of  mitral  obstruc- 
tion. Walshe  has  never  observed  the  thrill,  but 
believes  it  possible. 

14.  There  is  a  case  in  this  cit}^  now  in  which  the 
thrill  is  indubitable  ;  but  it  no  more  resembles 
the  purr  of  a  cat  or  the  hum  of  a  wheel  than  it 
does  the  filing  of  a  saw — but  it  does  accurately 
simulate  the  thrill  felt  by  placing  one's  finger  on 
a  gum-elastic  tube,  a  few  lines  in  diameter,  con- 
nected with  a  hydrant  with  the  water  turned  on. 
The  obstruction  of  the  water  produces  a  palpable 
thrill  and  an  audible  murmur  closely  simulating 
mitral  murmur  and  thrill  ;  but  in  the  case  to 
which  allusion  is  here  made,  mitral  regurgitation 
is  undoubted,  yet  neither  Walshe  nor  Hope  ever 
observed  the  thrill  in  any  valvular  disease.  It 
is  probable  that  the  occurrence  of  the  thrill  is 
extremely  rare,  and  in  a  diagnostic  point  of  view 
entirely  valueless,  for  pressure  on  any  blood- 
vessel by  any  substance  might  develope  a  thrill 
under  favorable  circumstances. 

15.  I  cannot  leave  this  disputed  ground  without 
one  more  allusion  to  Skoda's  very  positive  dicta 
— yet  it  should  be  observed  that  his  assertions 
are  unsupported  by  accompanying  clinical  facts, 
and  that  while  they  seem  logical,  they  are  nulli- 
fied by  the  case  cited  by  Walshe,  and  by  two  or 


THEIR    DIAGNOSIS    AND   THEATMENT.  93 

three  others  cited  by  Hope,  where  mitral  con- 
striction was  greats  and  yet  there  was  no  diastolic 
murmur. 

16.  But  to  Skoda  ;  he  says  :  "  The  more  con- 
stricted the  mitral  orifice  is,  the  longer  will  be 
the  time  necessary  for  the  flow  of  the  blood  into 
the  ventricle,  and  the  more  prolonged  and  louder 
the  murmur.  It  is  in  cases  of  this  kind  especially 
that  vibrations  are  felt,  when  the  hand  is  laid 
upon  the  prsecorclial  region/^ — the  cat-purr  of 
Laennec. 

17.  The  first  clause  of  this  quotation  is  obvi- 
ously exact ;  but  the  second,  ''  the  more  pro- 
longed and  louder  the  murmer/'  is  doubtful  in 
theory,  and  contradicted  by  the  facts  above  al- 
luded to.  The  blood  flowing  from  the  auricle 
through  a  smooth^  circular  or  regularly  elipliform 
contraction  into  the  ventricular  cavity,  would  be 
in  the  last  degree  unlikely  to  developc  a  murmur, 
however  great  the  hypertrophy  of  the  auricle. 
Liquid  flowing  through  the  constricted  end  of  a 
tube,  if  the  constriction  be  smooth^  does  not  gene- 
rate a  murmur,  unless  the  impelling  force  be 
relatively  (to  the  size  of  the  stream)  very  great. 

That  is,  murmur  depends  not  on  the  contrac- 
tion or  roughness  merely,  but  on  the  momentum 
of  the  liquid  flowing  through  the  aperture  ;  and 


94  DISEASES    OF   THE    HEART  . 

in  mitral  constriction  the  momentum  will  be 
slight,  except  in  cases  of  great  hypertrophy  of 
left  auricle,  and  only  in  such  cases  will  murmur 
be  likely  to  be  developed,  and  then  it  will  occur 
only  at  the  moment  of  the  auricular  contraction 7 
that  is,  barely  pre  systolic — so  near  the  systole  as 
to  be  easily  confounded  with  regurgitant  diastolic 
murmur  ;  and  as  the  mechanism  of  this  murmur 
is  the  same  as  that  of  the  regurgitant,  it  should 
be  no  mere  sighing,  but  should  have  the  same 
abrupt  blowing  character.  Liquid  flowing  with 
great  velocity  and  continuously  from  the  end  of 
a  tube  emits  a  sighing  murmur,  but  not  when  it 
depends  on  an  interrupted  vis-a-tergo,  like  the 
contraction  of  an  auricle  suddenly.  But  liquid 
flowing  through  a  constriction  in  the  continuity 
of  a  tube,  whether  the  constriction  be  rough  or 
smooth,  will  be  attended  with  murmur^  and  if 
rough  with  thrill  also  ;  and  in  cases  where  the 
thrill  is  manifest,  it  would  be  well  to  exclude 
aortic  regurgitation,  and  even  mitral  regurgita- 
tion, by  the  most  rigid  logic,  before  attributing 
the  thrill  to  constriction  of  the  mitral  orifice. 

18.  But  there  being  necessarily  any  murmur  at 
all,  and  e?=pecially  its  being  attended  with  palpable 
or  visible  thrill  would  seem  to  be  as  much  opposed 
to  theory  as  to  facts.  Still,  it  would  be  extremely 


95  THEIR   DIAGNOSIS   AND   TREATMENT. 

fortunate  if  we  had  some  sign  pathognomonic  of 
mitral  constriction,  for  it  is  the  one  of  the  affec- 
tions of  the  heart  next  to  aortic  regurgitation 
and  tricuspid  constriction  most  likely  to  teraii- 
nate  rapidly  and  suddenly,  and  it  is  one,  if  recog- 
nized positively,  that  may  be  treated  with  every 
expectation  of  prolonging  the  life  of  the  patient 
far  beyond  the  limit  it  would  reach  if  the  case 
were  left  to  itself.  Verification  of  hypertophous 
dilatation  of  the  left  ventricle,  exclusion  of  aortic 
regurgitation,  the  presence  of  pulmonic  conges- 
tion and  hemoptysis,  increased  second  sound  of 
pulmonary  artery,  a  feeble,  irregular,  unequal, 
intermittent  pulse,  would  render  positive  the 
existence  of  mitral  constriction,  even  if  no  mur- 
mur at  all  were  present. 

19.  Thus  in  constriction  of  this  orifice,  if  a  mur- 
mur be  developed  at  all,  it  will  immediately  pre- 
cede a  systolic  regurgitant  murmur,  and  will  be 
propagated  towards  the  left  apex,  and  diminish 
and  disappear  before  arriyin,!^  at  the  second  in- 
terspace. 

20.  Constriction  of  the  mitral  orifice  would 
add  to  the  unfavorable  prognosis  of  mitral  regur- 
gitation. The  same  principles  of  treatment  are 
applicable  here  as  in  other  cardiac  lesions.  The 
heart  must  not  be  alloVed  to  beat  too  fast — more 


96  DISEASES   OF   THE    HEART  : 

than  80 — the  weight  of  the  body  must  be  dimin- 
ished, while  tlie  quality  of  the  blood  is  maintained 
at  a  healthy  standard.  •  Abundant  passive  exer- 
cise in  the  open  air,  more  a  meat  than  vegetable 
diet,  a  quiet  mind,  slow  bodily  movements,  baths, 
diuretics,  aperients,  occasional  precordial  counter- 
irritation,  or  even  depletion  ;  all  these  may  be 
requisite,  according  to  the  condition  of  the  body 
and  the  general  health.  It  is  not  possible  to 
follow  any  prescribed  details  of  treatment  for 
any  length  of  time.  The  treatment  must  be  con- 
stantly modified,  to  suit  the  ever  varying  exi- 
gencies of  each  case. 


CHAPTER  V^I. 

Inorganic  Murmtjrs — How  Distinguishable  from  Or- 
ganic—Diastolic  Inorganic  Murmur. 

21.  In  a  former  chapter,  two  diagnostic  signs, 
one  of  endocarditis — a  murmur ;  one  of  pericar- 
ditis— a  friction  sound,  were  given.  It  was  not  said 
said  that  the  affections  could  exist  without  these 
relative  diagnostic  signs  ;  but  it  is  not  probable 
that  an  endocarditis  ever  occurs  and  runs  its 
course  without  developing  and  maintaioing  during 
much  of  its  progress  a  bellows  murmur.  It  is  not 
probable  that  the  friction  sound  is  ever  absent  at 
all  times  during  the  course  of  a  pericarditis. 


THEIR    DIAGNOSIS    AND    TREATMENT.  97 

a.  The  friction  sound  is  less  persistent' in  peri- 
carditis than  murmur  in  endocarditis,  because  of 
the  early  effusion  of  serum  in  the  former  affection 
by  which  the  serous  surfaces  are  kept  apart,  and 
thus  friction  prevented.  But  as  no  such  effusion 
takes  place  in  inflammation  of  the  heart's  cavities^ 
the  murmur  indicating  it  is  likely  to.be.  persistent 
until  its  termination  in  death,  recovery,  or  in 
permanent  unsoundness  of  the  heaf  t  without  in- 
flammation ;  in  the  latter  contingency,  the  7nwr- 
mur  continues  and  becomes  an  index  of  ^hi^onic 
disease  of  the  valves. 

22.  But  murtnurs  may  exist  and  closely  sfmu- 
late  endocardial  murmur,  from  inflammation  of 
the  inside  of  the  heart,  or  from  valvular  disease 
and  yet  they  may  indicate  neither  the  one  nor 
the  other.  Whenever  there  is  meclianical  im- 
pediment to  the  circulation  from  valvular  disease, 
thereJ  is  iti  almost  every  case  a  mi^rmwr  audible. 
But  there  are  murmurs  without  the  valvular  im- 
pediment, yet  not  without  cause  ;  but  this  cause 
is  not  always  an  impediment  to  the  circulation^ 

23.  Take,  for  example,  those  cases  in.  which 
the  murmur  comes  and  goes,  as  it  does  sometimes 
in  convalescence  from  rheumatic  endocarditis. 
Hejie  the  murmur  doubtless  depends  on  so«ie?^7 
struction  at  the  orifices  of  the  heart  wbiehi^,  sjo 

L 


98  DISEASES    OF   THE    HEART  : 

nearly  removed  by  the  process  of  recovery  as  to 
cause  a  murmur  only  during  exertion — during 
increased  action  of  the  heart ;  while  directly  the 
patient  is  in  repose  and  the  heart  has  had  rest, 
the  murmur  vanishes,  to  recur  upon  subsequent 
exertion,  and  finally  to  vanish  altogether  when 
the  patient  is  well. 

24.  A  patient  has  uneasiness  about  the  heart  ; 
it  is  even  painful.  The  pulse  is  accelerated  ;  the 
impulse  of  the  heart  is  increased  ;  the  sound 
louder  ;  nothing  more  ;  or,  perhaps  the  patient 
says  he  gets  fatigued  sooner  than  formerly  ;  no 
murmur  is  heard  on  auscultation,  if  the  patient 
have  been  some  moments  in  repose  ;  but  if  he  be 
directed  to  swing  his  arms  violently,  or  walk 
briskly,  and  the  ear  be  then  applied  to  the  pre- 
cordia,  endocardial  murmurs  are  immediately 
manifest,  and  gradually  vanish,  even  while  one 
is  listening.  Now,  here  then  is  possibly  the  be- 
ginning of  unsoundness  of  the  heart,  and  possibly 
the  murmur  is  the  result  of  some  alteration,  of  a 
temporary  character  in  the  quality  or  quantity 
of  the  blood  relatively  to  the  dynamic  condition 
of  the  heart  at  that  particular  time,  or  during  a 
period  of  one  or  more  days.  Should  the  murmur 
continue,  that  is,  become  persistent,  even  though 
it  continue  of  the  ^'  come  and  go'^  character,  it  is 


THEIR    DIACxNOSIS    AND    TREATMENT.  99 

an  organic  murmur,  simply  because  inorganic 
murmurs  from  spaneemia,  or  merely  dynamic 
changes  in  the  heart  itself,  are  in  the  very  nature 
of  the  proposition  not  persistent,  because  their 
cause  is  not  persistent,  neither  in  its  existence 
nor  in  its  consequences. 

25.  There  are  cases  in  which  a  systolic  mur- 
mur is  developed  immediately  before  death  ;  and 
in  the  absence  of  post-mortems,  it  is  impossible  to 
say  whether  such  murmurs  are  the  result  of  in- 
flammatory action — pericarditis — set  up  at  that 
moment,  of  coagulation  of  the  blood  near  the 
pulmonic  or  aortic  orifices,  of  coagulation  in  the 
mitral  orifice,  by  which  its  valves  are  rendered 
incompetent,  of  span^emia,  or  finally  of  dynamic 
alterations  in  the  heart  itself,  occurring  immedi- 
ately before  dissolution  ;  and  the  inquiry  for  the 
cause  is  unprofitable,  for  the  patient  dies,  and 
the  murmur  is  a  mere  declaration  that  death  is 
imminent,  and  no  longer  to  be  warded  off. 

26.  A  murmur  is  easily  developed  in  children, 
by  pressure  of  the  ear,  or  of  the  stethoscope, 
when  there  is  no  cause  of  a  murmur  within  the 
body,  a,  A  murmur  may  occasionally  be  de- 
veloped in  adults  in  the  same  manner,  but  in  such 
case,  the  practised  ear  will  easily  distinguish  tlie 
false  from  the  true  murmur  by  its  quality.     /;. 


IQO         '  -BISEASES     OF   THE    HEART  ! 

Chicken- breast,  though  scarcely  a  deformity,  may 
so  displace  and  impinge  the  heart  as  to  develope 
a  murmuri  Increase  of  area  of  precordial  dull- 
ness to  percussion,  and  extensive  precordial  im- 
pulse, are  diagnostic  signs  of  hypertrophy.  Yet 
both  these  signs  occur  in  chicken-breast  ;  and  if 
to  these  be  added  a  systolic  murmur,  we  have  the 
complete  signs  of  hypertrophy  with  valvular  dis- 
ease; and  yet  there  is  neither  the  one  nor  the 
other.  Iri  this  case  the  murmur  is  easily  pro- 
duced, if  absent,  by  the  pressure  of  the  stetho- 
scope'/   ' 

tnuC'  Tie  respiratory  murmur  can  be  excluded  as 
a  source  of  .error,  by  directing  the  patient  to  hold 
his  breath  an  instant,  d,  Latham  says  a  murmur 
4s  often  heard  between  the  upper  edge  of  the 
'Second  and  the  lower  edge  of  the  third  left  costal 
cartilage,  and  an  inch  along  and  between  each  of 
these  ribs  the  murmur  is  systolic  bellows-like, 
unmistakable  in  character.  At  the  same  time  it 
is  heard  nowhere  else  in  the  heart,  or  arteries, 
or  lungs.  It  occurs  in  phthisical  patients,  or  in 
those  who  are  justly  suspected  of  being  so.  Whe- 
ther this  murmur  proceed  from  tlie  pulmonary 
^artery  in  its  first  division,  in  consequence  of  its 
own  disease,  or  in  consequence  of  pressure  upon  it 
from  consolidated  or  altered  lung,  is  unknown. 


THEIR    DIAGNOSIS   AND   TREATMENT.  101 

Whenever  there  is  suspicion  of  tuberculosis,  the 
presence  of  this  murmur  will  tend  to  confirm  it  ; 
otherwise,  it  has  no  known  value. 

27.  There  is  also  the  well  known  anemic  mur- 
mur. These  murmurs  may  be  present  not  only 
in  typical  anemia — aglobulia — that  is,  defect  of 
red  blood  globules,  but  also  in  hemorrhagic  ane- 
mias, in  typhus,  in  cholera,  in  all  exhaustive 
afi'ections,  and  in  alm^ost  every  variety  of  span 83- 
mia. 

28.  Just  how  depravity  of  the  blood  causes 
murmurs  in  the  heart,  we  cannot  say  ;  but  the 
fact  remains  ;  and  so  soon  as  we  remove  the  blood 
disease,  the  murmur  disappears  and  returns  no 
more.  The  anemic  murmur  cannot  be  confounded 
with  that  of  unsound  valves,  on  account  of  the 
accompanying  symptoms.  These  are  overwhelm- 
ing in  number  and  obviousness  :  '*  the  surface  Dale 
and  cold,  palpitation  and  dyspnoea,  appetite  per- 
verse, digestion  imperfect,  nutrition  insufficient, 
secretions  scanty  and  unhealthy,  pain  every- 
where, a  shattered  nervous  system  and  an  enfee- 
bled brain."  These  are  not  symptoms  of  unsound 
heart,  but  almost  peculiar  to  anemia. 

29.  It  has  been  considered  a  law,  that  a  dias- 
tolic murmur  proceeding  from  the  heart  is  always 
an  organic  murmur,  and  that  if  it  take  the  place 


102  DISEASES    OF    THE    HEART  : 

of  the  second  sound,  it  is  of  valvular  origin — 
semilunar — but  there  is  reason  to  believe  that  a 
diastolic  murmur  may  be  generated  in  certain 
dynamic  conditions  of  the  heart,  depending  upon 
defective  innervation,  through  particular  nerve 
filaments,  by  which  the  function  of  a  segment  of 
a  valve  might  be  temporarily  impaired  so  as  to 
render  the  whole  valve  incompetent  for  a  limited 
period.  A  clot  might  also  so  entangle  a  valve 
as  to  prevent  its  closure  for  a  time,  and  yet 
eventually  be  all  washed  away  and  carried  iiito 
the  torrent  of  the  circulation,  either  in  complete 
solution  or  as  emboli,  to  cause  obstructions  in 
remote  organs.  Walshe  says  that  he  has  met 
with  some  few  instances  of  inconstant  murmur- 
like quality  of  the  diastolic  sound  at  the  base, 
which  appeared  to  him  to  be  possibly  dependent 
on  disordered  dynamism  of  the  aortic  valves. 
*'  It  remains  for  future  inquiries  to  determine, 
also,  whether  temporary  reflux,  with  its  murmur, 
may  not  be  caused  by  dynamic  imperfection,  with- 
out structural  change  in  the  valves." 

30.  Those  haemic  murmurs  that  characterize 
aneurisms,  or  indicate  pressure  on  arterial  or 
venous  trunks,  by  abnormal  growth,  or  foreign 
bodies,  either  in  or  out  of  the  body,  are  excluded 
from  consideration  in  this  estimate  of  inorganic 
murmurs. 


THEIR   DIAGNOSIS   AND   TREATMENT.  103 

There  is  little  doubt  that  one  accustomed  to 
auscultation  of  the  heart  would  distinguish  an 
inorganic  from  an  organic  murmur,  in  almost 
every  case,  by  the  mere  quality,  pitch,  tone, 
streno;th  and  duration  of  the  murmur  alone. 


CHAPTER  VII. 

Pericarditis  and  Endocarditis.    Endo-pericarditis — 
Carditis. 

31.  By  inflammation  of  the  heart's  membranes, 
is  understood  something  altogether  different  from 
"  disease  of  the  heart.''  The  latter  phrase  is 
vulgarized  in  and  out  of  the  profession  so  as  to 
mean  the  concrete  condition  of  the  heart  in  a 
state  of  chronic,  not  acute,  unsoundness.  Inflam- 
mation of  the  heart's  membranes  is  a  phrase  the 
import  of  which  would  be  understood  by  the  pro- 
fession, and  the  use  of  which  is  limited  to  the  pro- 
fession. It  is  divided  into  two  varieties,  one  per- 
taining to  the  inside — endocarditis — the  other  to 
the  outside  of  the  heart — pericarditis.  These 
two  affections  originate  in  similar  though  not  con- 
tinuous membranes  ;  the  one,  endocarditis,  attacks 
the  lining  membrane  of  the  heart's  cavities  ;  the 
other,  pericarditis,  attacks  their  investing  mem- 
brane— the  sack  in  which  the  heart  is  enveloped. 


104  DISEASES   OF    THE    HEART  : 

a.  Omitting  details  of  gTeat  interest,  but  not  ab- 
solutely necessary  to  accurate  diagnosis,  these 
diseases  are  distinguished  by  signs  so  exclusively 
characteristic,  that  if  the  heart's  membranes  are 
inflamed  at  all,  it  can  generally  be  made  out 
whether  the  affection  is  one  or  both  of  the  varie- 
ties mentioned. 

h.  The  characteristic  sign  of  endocarditis  is 
an  endocardial  murmur^  systolic  in  time,  occur- 
ring suddenly  in  a  person  with  fever  or  acute 
rheumatism,  in  whom  it  had  never  occurred  be- 
fore. One  can  never  be  absolutely  certain  of  the 
endocardial  inflammation,  until  the  bellows  mur- 
mur  is  heard,  no  matter  how  great  the  pain  in 
the  heart,  how  gred-t  the  palpitation,  how  irreg- 
ular, or  intermittent  or  unequal  the  pulse,  or  how 
hot  and  livid  the  skin.  Treatment  of  course 
should  not  be  postponed  until  the  murmur  be 
heard,  neither  can  it  be  positively  said  there  is 
no  endocarditis  before  the  murmur  is  heard  ;  but, 
on  the  contrary,  it  may  be  reasonably  suspected 
without  the  murmur;  but  not  positively  made 
out.  c.  The  murmur  is  essential  to  the  positive 
diagnosis,     (Latham.) 

c/.  The  murmur  occurring  for  the  first  time, 
during  the  presence  of  constitutional  inflamma- 
tory symptoms,  determines  that  the  general  in- 
flammation has  touched  the  endocardium. 


THEIR    DIAGNOSIS    AND    TREATMENT.  105 

e.  The  seat  of  the  greatest  intensity  of  the 
murmur  determines — in  limits — the  chief  seat  of 
the  inflammatory  process.  The  murmur  is  usually 
heard  loudest  at  those  parts  of  the  thoracic  walls 
which  are  nearest  that  portion  of  the  heart  from 
which  the  murmur  originates.  A  systolic  mur- 
.mur  may  be  heard  over  the  right  or  left  ventricle, 
or  over  the  aorta  alone,  or  over  the  pulmonary 
artery,  or  over  two  or  more  of  these  parts  at  the 
same  time. 

/.  The  sounds  may  be  normal,  or  louder,  or 
duller,  or  more  indistinct,  or  shorter  than  natural, 
and  at  times  they  may  be  almost  inaudible,  from 
the  weakness  or  temporary  restraint  of  the  hearths 
contractions  ;  or,  in  consequence  of  great  ejffusion 
in  the  sac  of  the  pericardium,  when  that  mem- 
brane is  also  affected. 

g.  The  valves  are  sometimes  rendered  incom- 
petent for  a  few  hours  or  days  only,  and  during 
this  time  a  murmur  of  regurgitation — mitral — 
may  be  heard  at  left  apex,  or  a  diastolic  murmur 
may  be  heard  over  the  third  left  cartilage,  and 
thence  down  the  sternum  from  incompetency  of 
the  aortic  valves. 

32.  If  the  pulmonic  valves  should  become  in- 
competent, (a  thing  which  scarcely  ever  occurs,) 
a  diastolic  murmur  would  be  heard,  loudest  in 
second  (pulmonic)  interspace,  and  thence  directly 

M 


106  DISEASES    OF    THE    HEART  : 

upwards.  The  aortic  diastolic  murmur  is  not  in- 
frequent after  the  first  few  days  of  endocarditis. 
33.  Pericarditis  is  not  known  to  be  an  idio- 
pathic disease.  It  is  chiefly  the  result  of  acute 
rheumatism  ;  rarely  of  Bright's  disease  of  the 
kidneys.  It  may  attend  or  directly  follow  ^ny 
of  the  exhaustive  diseases — as  typhoid  fever, 
variola,  scarlatina,  diphtheria,  pyaemia  frequently, 
(one  in  seven  cases  of  pyaemia  have  pericarditis, 
but  pysemia  itself  is  very  rare)  ;  it  is  sometimes 
associated  with  pleuritis,  or  pleuro-pneumonia, 
but  has  no  known  dependency  on  the?e  lesions  ; 
with  albuminuria  from  any  cause — wherever  there 
is  albuminuria,  the  heart  should  be  watched  for 
endo-pericarditis.  I  have  seen  it  with  scurvy  in 
three  instances  in  the  late  civil  war  ;  with  influ- 
enza, erysipelas  and  consumption;  hepatic  abscess 
of  left  lobe — a  case  observed  by  the  author  at  Fort 
Yuma  in  1861,  verified  by  post-mortem  examina- 
tion— very  rarely  with  cancerous  and  tuberculous 
diatheses.  Of  course  it  may  be  produced  by  any 
direct  injury  to  the  pericardium,  as  wounds, 
blows,  fractured  ribs.  etc. 

It  is  more  likely  to  follow  or  attend  rheu- 
matism in  youths  than  in  adults  ;  in  females  than 
in  males  ;  hence  it  is  more  frequent  in  these 
classes  of  persons  than  in  adult  males.  Soldiers 
are  more  liable  to  scurvy  than  civilians,  hence 


THEIR   DIAGNOSIS   AND   TREATMENT.  107 

they  are  more  liable  to  pericarditis  and  endo- 
pericarditis  from  this  cause. 

a.  Its  moir't  obvious  "^jmi^tom  is  the  anxious  and 
drawn  expression  of  the  features,  and  the  abso- 
lute immobility  of  the  patient,  as  to  voluntary 
muscular  motions  ;  but  this  symptom  is  not  al- 
ways present,  and  when  present  is  also  a  sign  of 
pleuritis. 

6.  The  characteristic,  the  diagnostic  audible 
sign  is  a  friction  murmur,  or  rather  a  friction 
sound.  If  one  attempts  to  describe  the  abnormal 
murmur  he  hears  in  pericarditis,  it  will  be  by 
some  similie  into  which  enters  the  friction  of  two 
surfaces  of  a  greater  or  less  degree  of  moisture, 
or  dryness,  or  roughness.  It  would  never  occur 
to  imitate  the  friction  sound  of  pericarditis  by 
modifications  of  the  respiratory  act,  while  it 
would  never  occur  to  imitate  the  '*  bellows  mur. 
mur'^ — ''  bruit  de  souffle f  murmur  of  endocarditis 
in  any  other  manner  except  one  called  in  the  aid 
of  external  atmospheric  murmurs. 

The  friction  sound  may  be  loud  or  low-toned, 
sharp  or  dull,  single  or  double,  but  it  always  sug- 
gests the  idea  of  attrition,  and  never  that  of 
expiration  or  inspiration,  or  blowing  ;  and  so  the 
contrary. 

b.  The  chief  local    symptom  of  pericarditis  is 


108  DISEASES   OF   THE   HEART. 

pain  (Walshe)  ;  but  the  same  author  says  that  in 
the  majority  of  cases  pain  is  either  absent  or  of 
slight  severity. 

c.  The  pericardium  is  peculiarly  insensible 
when  inflamed,  in  Bright s  disease,  and  patients 
often  persist' in  denying  the  existence  of  symp- 
toms referable  to  the  heart  ;  but  in  these  cases 
pressure  with  the  flat  hand  over  the  heart  will 
cause  a  degree  of  uneasiness  which  is  intolerable, 
although  it  may  not  be  precisely  pain  ;  and  this 
insensibility  is  not  confined  to  pericarditis  in 
Bright's  disease,  but  occurs  especially  in  asthenic 
pericarditis.  Hence  the  **  chief  local  symptom'^ 
(pain)  avails  little  in  diagnosis,  much  less  than  im- 
mobility and  lying  on  tlie  back,  the  anxious  look, 
attendant  rheumatism  and  inflammatory  febrile 
pulse. 

d.  The  distinction  between  endocardial  mur- 
mur and  exocardial  friction  is  occasionally  im- 
possible.    (Walshe.) 

e.  There  may  or  may  not  be  bulging  of  the 
precordia  from  pericardial  efi'usion.  There  may 
or  may  not  be  friction — fremitus — appreciable  to 
palpation.  The  heart's  impulse  is  generally 
greater  in  extent  but  not  in  force,  and  may  even 
be  much  weaker  than  natural. 

h.  Pericardial  effusion  may  develope  apparently 
endocardial  systolic  murmurs,  by  pressure  on  the 


THEIll    DIAGNOSIS   AND    TREATMENT.  109 

roots  of  the  great  vessels,  thus  leading  to  the 
suspicion  of  endocarditis,  when  the  endocardium, 
valves  and  vessels  may  be  entirely  healthy. 

34.  It  is  believed,  also,  that  pleuritic  effu- 
sions, in  very  rare  instances,  so  contort  the  ves- 
sels at  their  orifices  as  to  produce  incompetency 
of  valves,  thus  causing  diastolic  murmurs  heard 
even  at  the  apex  and  down  the  sternum,  the  pecu- 
liar seats  of  orgastic  regurgitant  murmurs, 

35.  I  recently  saw,  for  a  few  moments,  during 
my  first  and  only  visit,  a  case  of  pericarditis^ 
remarkable  for  the  rapidity  of  its  progress  and 
for  its  fatal  termination.  When  I  saw  the 
patient,  he  was  suffering  with  frightful  dyspnoea, 
which  was  supposed  by  his  attendants  to  be 
**  asthma,  aggravated  by  wind  on  the  stomach" — 
[There  was  epigastric  fullness,  which  is  not  un- 
common in  pericarditis,  second  stage]  —  for 
which  they  were  administering  stimulants  and 
nauseants,  in  bulky  doses,  to  cause  emesis  ;  the 
patient  was  held,  sitting  upright,  although  he 
desired  to  lie  down  ;  his  skin  was  livid  and 
bathed  in  viscid  perspiration  ;  his  pulse  was 
exceedingly  rapid,  small,  irregular,  intermittent, 
unequal  ;  his  extremities  cold  ;  his  voice  reduced 
to  a  whisper  ;  deglutination,  even  of  fluids,  diffi- 
cult. Percussion  of  the  precordia  was  impracti- 
cable, but   during  the  instant  I  listened  at  the 


110  DISEASES    OF   THE   HEART: 

heart,  I  heard  a  dull,  wet*  second  sound,  (no  first 
sound,)  and  a  faint  murmur,  systolic  in  time — no 
friction  sound.  My  diagnosis,  to  my  own  mind, 
was  rapid  but  not  exhaustive  :  pericarditis,  with 
either  very  considerable  effusion,  incompetent 
mitral  valves,  or  fatty  heart  with  incompetent 
mitral  valves.  The  fatty  heart  was  rendered 
doubtful,  by  the  persistence  of  the  pulse,  which 
in  the  last  hours  of  this  affliction  is  generally 
absent,  or  answers  to  the  systoles  perhaps  ten  or 
twenty  times  only  in  a  hundred.  The  absent 
first  sound  was  as  accountable  on  the  supposition 
of  effusion,  as  of  softened  heart  ;  t  hence,  on  the 
pulse  alone,  I  excluded  the  latter.  I  had  the 
melancholy  good  fortune  to  assist  at  the  j)ost 
mortem^  some  forty-eight  hours  later.  The  left 
ventricle  was  generally  dilated  ;  the  mitral  valves 
were  incompetent  from  analogous  deposits ;  the 
beginning  of  the  aorta  was  atheromatous  ;  there 
were  some  patches  of  lymph  on  the  vir-ceral  du-* 
plicature  of  pericardium,  and  very  considerable 
serous  effusion  ;  amount  not  measured,  but  sup- 
posed to  reach  eight  ounces.  The  proper  tissue 
of  the  heart  was  softer  than  natural — not  ex- 
amined microscopically. 


*  A    sound   like    that    of  striking   a    table  with   a  wet 
napkin. 

f  See  Appendix  F. 


THEIR    DIAGNOSIS   AND   TREATMENT.         Ill 

The  duration  of  this  case  might  have  been 
indefinitely  prolonged,  had  the  serious  damage 
to  the  heart  been  recognized  at  the  beginning 
instead  of  the  end  of  the  last  week  of  life.  A 
recumbent  position,  aconite  and  veratrum  viride 
in  minute  and  alternate  doses,  saline  evacuants,  "^ 
saline  diuretics,  leGches  and  cups  at  the  precordia, 
sinapisms  to  the  knees,  ankles  and  elbows,  sus- 
pension of  food,  except  beef  juice  in  small  quan- 
tity, no  stimulants,  properly  so  called,  except  on 
the  special  indication  of  failing  pulse  and  threa- 
tened syncope  ;  then,  brandy,  or  ammonia  and 
lavender.  With  this  treatment  from  the  begin- 
ning, it  is  probable  that  the  pericarditis  would 
have  terminated  in  complete  recovery  ;  the  mitral 
disease  being  slight,  would  have  been  harmless 
for  the  time  ;  the  fatty  degeneration,  if  certainly 
present,  which  was  not  proved,  would  not  neces- 
sarily have  caused  death  so  soon. 

36.  There  seems  to  be  great  discrepancy  in 
authors,  Latham  and  Skoda,  for  example,  con- 
cerning the  distinctive  characters  oi  friction  sound 
(exocardial)  and  bellows  murmur  (endocardial). 

37.  To  my  mind  it  is  clear  that  a  sound  whose 
similie  is  friction  must  in  the  natu  re  of  the  propo- 
sition  be  dissimilar  from  one  whose  similie   is 


Bee  Appendix  G. 


112  DISEASES    OF   THE    HEART! 

murmur  ;  and  this  is  the  precise  actual  difference 
between  the  two  murmurs.  They  are  recognized 
by  distinct  names,  friction  murmur  and  bellows 
murmur^  all  through  the  literature  of  diseases  of 
the  heart,  from  Corvisart  to  Walshe. 

38.  Walshe  and  others  say,  the  murmur, 
when  there  is  doubt  of  its  extra.-  or  intra-cardiac 
origin,  may  be  identified  as  exocardial,  by  being 
more  superficial  and  more  diffused  than  endocar- 
dial murmurs,  Skoda  says  flatly  that  in  his 
opinion  they  cannot  be  so  distinguished.  Boillaud 
experienced  great  difficulty  in  discriminating 
attrition  and  valvular  murmurs. 

39.  Hope  makes  the  distinction  by  no  means 
difficult.  The  existence  of  the  two  classes  of 
murmurs  is  indubitable,  as  all  writers  on  the 
heart,  since  Collin,  in  1824,  distinguish  them  as 
being  referable  ;  the  valvular  murmurs  to  the 
endocardium ;  the  attrition  murmurs  to  the  exo- 
cardium. 

40.  Skoda  recognizes  the  existence  of  the  two 
classes  of  murmurs.  After  acknowledging  the 
new-leather  attrition  sound,  which  is  very  rare,  the 
rustling  and  rubbing  sound  (frequent),  the  scratch- 
ing sound,  from  bony,  chalky,  or  fibro-cartilagi- 
nous  concretions,  rubbing  against  each  other,  or 
some  part  of  the  pericardium  during  the  heart's 
movements,  he  says  :  "  There  is  no  doubt  that  all 


THEIR    DIAGNOSIS    AND    TREATMENT.  113 

these  different  friction  sounds  of  the  pericardium 
have  a  real  existence.  -se-  ^  ^  *  ^ 
According  to  my  own  experience,  there  is  no  kind 
of  endocardial  murmur,  with  the  exception  of  the 
whistling,  which  may  not  be  imitated  by  a  fric- 
tion sound  of  the  pericardium  ;  and  no  pericardial 
murmur  which  may  not  resemble  an  endocardial 
murmur.^' 

41.  Hope  and  Markuam  believe  the  distinction 
of  the  murmur  from  the  friction  not  difficult  ;  the 
former  did  not  find  it  difficult  to  discriminate 
between  attrition  sounds  and  murmurs,  ''  even 
when  the  two  classes  of  sounds  existed  simulta- 
neously and  each  was  double.'^  The  former  dis- 
criminates by  listening  for  the  murmurs  of  the 
semi-lunar  valves  two  or  more  inches  up  the  aorta 
or  pulmonary  artery,  where  attrition  murmurs  are 
generally  inaudible ;  and  by  listening  to  the 
murmurs  of  the  auriculo-ventricular  valves,  a 
little  above  the  apex  of  the  heart,  where  they  are 
sure  to  be  loudest,  whereas,  attrition  murmurs 
may  be  louder  at  other  parts  of  the  heart  where 
they  happen  to  be  generated. 

42.  He  further  distinguishes  them  by  the  fol- 
lowing peculiarities  : 

a.  Attrition    murmurs    have    usually  a    much 

N 


114  DISEASES    OF    THE    HEART  : 

rougher  quality  of  sound  than  the  valvular  mur- 
mur, so  that  when  the  two  co-exist,  the  one  may 
be  hoard  through  the  other. 

b.  When  a  murmur  with  the  second  sound  is 
rough,  as  rasping,  creaking,  croaking,  etc.,  it  is 
certainly  from  attrition. 

43.  Second  sound  valvular  murmurs — diastolic 
murmurs — are  never  rough,  as  the  diastolic  cur- 
rents are  in  the  nature  of  the  forces  causing  them, 
too  feeble  to  produce  rough  murmurs.  A  diastolic 
mitral  murmur  is  faintly  audible;  a  diastolic  aortic 
murmur  is  louder,  but  still  smooth.  Diastolic 
pulmonic  murmurs  almost  never  occur..  Systolic 
tricuspid  murmur  is  known  by  its  smooth  blow- 
ing quality,  and  by  the  attending  jugular  pulse. 

44.  ''  Attrition  murmurs  are  almost  always 
attended  by  vibratory  tremor."  This  "  tremor" 
I  have  never  been  able  to  verify,  even  where 
pericarditis  was  undoubted  before  and  verified 
after  death. 

45.  Markham  says :  '*  a  fremitus  is  said  to  be 
sometimes  felt  over  the  precordial  region  when  the 
hand  is  laid  thereon."  Skoda  places  no  reliance 
upon  this  sign.  On  the  contrary,  Latham  relied 
greatly  upon  it  as  a  distinctive  sign.  He  has 
often  seen  an  undulatory  motion  between  the 
cartilages  of  the  second  and  third  ribs,  or  be- 


THEIR    DIAGNOSIS   AND   TREATMENT.  115 

tween  cartilages  of  third  and  fourth  ribs,  left 
side,  during  the  dull  percussion  and  exocardial 
murmur  period  of  pericarditis.  He  also  often 
felt  vibratory  motion  in  the  same  interspaces, 
second  and  third,  and  nowhei'e  else.  The  undu- 
latory  motion  and  vibratory  motion  often  oc- 
curred simultaneously,  but  he  thought  the  vibra- 
tion the  more  frequent.  They  were  sometimes 
present  between  the  cartilages  of  second  and 
third,  and  third  and  fourth  left  ribs,  simultane- 
ously— tactile  fremitus, 

46.  Walshe  says  it  is  rarer  and  more  migra- 
tory and  superficial  to  the  touch  than  valvular 
thrill,  distinguished  from  pleural  fremitus  by 
causing  the  patient  to  hold  his  breath  ;  not  im- 
plicitly reliable,  because  its  mechanism  is  un- 
known, and  it  may  arise  from  causes  external  to 
the  pericardium,  and  be  present  during  suspen- 
sion of  the  breath.  But,  if  present  with  the  exo- 
cardial friction,  it  is  a  valuable  aid  in  the  diag- 
nosis. 

47.  Stokes  says,  attrition  murmurs  are  apt  to 
undergo  frequent  and  sudden  changes  of  char- 
acter and  of  situation  which  are  very  pathogno- 
monic, because  valvular  murmurs  change  little  in 
character,  and  not  at  all  in  situation. 

48.  This  last,  though   agreeing  with  Walshe, 


116  DISEASES    OP   THE    HEART: 

Hope  and  others,  is  very  discrepant  with  La- 
tham, who  never  observed  the  fremitus,  except 
in  the  second  and  third  left  cartilage  interspaces. 
Can  it  be  possible  so  careful  an  observer  as 
Latham  mistook  a  pulmonic  valvular  thrill  for  a 
pericardial /remito  ? 

49.  Finally,  concerning  the  murmurs.  It  is 
probable  they  are  distinguishable  by  most  ob- 
servers— the  attrition  from  the  valvular — or  that 
the  cases  in  which  they  are  undistinguishable  are 
exceedingly  rare,  or  that  there  are  cases  in  which 
both  classes  of  sounds  occur,  each  being  modified 
by  the  other,  so  that  each  becomes  unrecognizable 
for  a  longer  or  shorter  period  ;  but  patient  and 
repeated  observation  would  in  the  end  discrimi- 
nate in  almost  every  case  between  an  attrition 
and  valvular  murmur. 

50.  But  it  is  of  no  vital  importance  whether 
the  distinctive  diagnosis  be  made  at  all,  for  the 
two  diseases  are  essentially  similar  in  immediate 
effects,  and  in  indications  of  treatment  ;  and  the 
indications  of  treatment  are  by  far  of  greater 
importance  than  any  theoretical  considerations  of 
the  distinctive  characters  of  the  two  diseases. 

51.  Pericarditis  is  a  much  less  frequent  disease 
in  warm  than  in  cold  climates,  other  things  equal. 


THEIR    DIAGNOSIS   AND    TREATMENT.  117 

It  is  by  no  means  so  frequent  in  San  Francisco  as 
in  Edinburgh  or  London. 

52'.  In  more  than  a  hundred  cases  of  rheuma- 
tism treated  by  me  in  Arizona  and  Southern 
California  during  the  years  1862  and  1863,  I  saw 
but  one  in  which  I  was  able  to  verify  that  the 
inflammation  had  afiected  the  heart ;  yet  in  every 
case  I  sought  diligently  and  frequently  the  symp- 
toms of  rheumatic  carditis. 

The  following  is  from  my  notes  of  this  case 
taken  in  the  field. 

Case  of  Acute  Endocarditis^  apparently  idio- 
pathic^ with  Emboli. — Argo,  a  soldier,  aged  25, 
tall,  fair-haired,  muscular,  came  on  the  sick  list 
for  a  cough.  Ordered  brown  mixture — he  did 
not  seem  much  sick. 

Second  day.  Argo  breathed  short;  •had  fever 
in  the  evening.  Ordered  saline  purge  and  qui- 
nine, five  grains  with  half  a  grain  of  opium,  when 
his  fever  should  go  ojQf;  continue  cough  mixture. 
He  had  no  crepitation  in  chest  ;  some  few  rather 
coarse  rales  ;  no  pain  in  the  chest,  but  coughed 
severely  at  times  ;  little  or  no  expectoration  : 
respiration  45  ;  pulse  110,  feeble,  small. 

Third  day.  A.  has  an  anxious  look  face  cada- 
veric and  perspiring  ;  appearance  of  great  agony, 


118  DISEASES    OF   THE   HEART  : 

but  he  is  able  to  walk  ;  his  respiratien  45  ;  pulse 
90,  very  weak  and  small ;  nails,  ears,  lips,  etc., 
livid  ;  says  he  has  no  pain,  but  feels  "  tight  here," 
placing  his  hand  on  the  sternum,  at  its  junction 
with  fourth  and  fifth  ribs. 

Auscultation  revealed  no  abnormal  sounds  in 
either  of  the  lungs  ;  over  some  portions  of  the 
lung  respiration  scarcely  audible,  and  in  other 
small  portions,  no  air  entered. 

The  hearths  impulse,  at  the  fifth  space  to  the 
right  of  left  nipple,  very  feeble  ;  sounds  are  ex- 
ceedingly weak.  There  was  something  indetermi- 
nable and  undefinable  about  the  quality  of  the 
stytole,  and  this  with  the  tightness  over  the  base 
of  the  heart,  made  me  uneasy  about  the  result. 
Ordered  cups  and  sinapisms  over  the  precordia, 
syrup  of  ijenega  for  the  cough,  and  beef  tea  for 
diet.  At  four  a.  m.  he  died,  without  any  of  the 
nurses  in  his  ward  observing  him  until  he  was 
quite  dead.  They  heard  a  very  "  wheezy  breath- 
ing" a  few  moments  before  he  was  found  dead. 

Post-mortem  at  nine  a.  m.  same  day.  On  open- 
ing thorax,  anterior  aspect  of  lungs  appeared 
natural  ;  no  adhesions  of  either  lung  ;  no  tuber- 
cles. On  lifting  out  lungs,  lower  lobes  of  both 
were  found  congested  posteriorly,  and  very  dark, 


THEIR   DIAGNOSIS   AND   TREATMENT.  119 

with  fluid  blood  ;  upper  lobe  of  right  lung  con- 
gested posteriorly. 

Size  of  heart  and  external  aspect  normal ;  no 
effusion  in  pericardium  ;  no  lymph  patches,  no 
white  spots,  nor  congested  coronary  vessels.  On 
removing  and  washing  heart,  in  both  right  and 
left  ventricles  were  found  pale  clots,  like  strips 
of  washed  muscle  wound  and  interlaced  with 
fleshy  columns  and  tendinous  cords,  and  under 
the  valves.  The  right  auricle  was  completely 
plugged  with  a  semi-organized  looking  clot, 
which  I  peeled  out  from  its  matrix,  as  a  false 
membrane  peels  out  from  the  sinuosities  of  the 
fauces.  These  clots,  after  being  removed  and 
thoroughly  washed  of  all  their  soluble  portions, 
weighed  ninety  grains.  The  endocardium  pre. 
sented  numerous  signs  of  inflammation,  especially 
about  the  auricles  and  valves  ;  left  auricle  con- 
tained no  clot  ;  valves  were  competent,  and  no 
orifice  was  appreciably  constricted.  These  clots 
must  have  been  formed  before  death,  which  evi- 
dently occurred  the  moment  the  right  auricle 
became  so  filled  with  the  clot  that  no  more  blood 
could  enter  and  pass  through  it  from  the  vencs 
cavce. 

The  man  lived  four  days  after  he  first  com- 
plained of  '*  tightness  in  the  chest."   At  the  time 


120  DISEASES   OP   THE  HEART  : 

of  this  occurrence,  there  were  many  cases  of 
rheumatism  in  camp,  which  was  attributed  to 
sleeping  on  the  green  salt  grass,  with  only 
one  blanket.  I  do  not  think  this  was  a  case 
of  simple  embolism  from  the  accidental  de* 
velopment  of  the  coagijjlatlng  principle  ^  of  the 
blood,  and  I  am  sure  it  did  not  result  from  fatty 
degeneration  of  the  heart,  by  which  it  was  ren- 
dered incapable  of  emptying  its  cavities,  for  the 
heart's  substance  was  firm,  and  normally  free 
from  fat. 

54.  During  the  last  four  years,  I  have  seen 
several  cases  of  pain  and  uneasiness  about 
the  heart  during  the  course  of  acute  rheumatism. 
In  one  there  was  great  anxiety  of  expression, 
and  extremely  small  and  feeble  pulse,  which 
made  me  fear  carditis  and  the  formation  of  em- 
boli,  I  gave  in  this  case  whiskey  and  water, 
alternated  with  fluid  extract  of  digitalis,  in  minute 
doses,  every  hour,  without  interrupting  the  usual 
rheumatic  treatment  with  propylamin  and  lau- 
danum.    The  patient  recovered. 

55.  The  treatment  of  pericarditis  and  endo- 
carditis, or  the  two  conjoined,  is  essentially  the 
same. 


*  On  Embolism,  see  Appendix  H. 


THEIR    DIAGNOSIS    AND    TREATMENT.         121 

56.  The  diet  must  be  diminished  in  quantity 
a'nd  in  blood-making  quality,  if  the  disease,  as 
most  frequently  happens  is  of  acute  rheumatic 
origin — in  othei;  words,  if  it  is  sthenic  in  quality. 

57.  Blood  may  be  taken  (if  the  patient  be  full- 
blooded,  or  in  good  blood-making  condition,) 
from  the  arm,  to  the  extent  of  a  pound,  early  in 
the  attack,  the  earlier  the  better,  and  this  may 
be  followed  by  five,  ten  or  twenty  leeches  (ac- 
cording to  the  violence  of  the  attack  and  condi- 
tion of  particular  case,)  to  the  precordia,  and 
these  may  be  followed  by  compresses,  wrung  out  of 
hot  water,  laid  over  the  leech  bites,  not  merely 
to  promote  the  flow  of  blood,  but  to  alleviate  the' 
precordial  anxiety  and  tightness  of  the  chest, 
which  will  be  thus  accomplished  in  a  surprising- 
manner. 

58.  The  dose  of  propylamin,  providing  we  are* 
treating  the  rheumatism  with  propylamin,  may 
be  quadrupled  immediately. 

59.  If  the  heart  beats  more  than  90,  and  espe- 
cially if  its  beats  are  not  rhythmical,  half  a  drop 
of  fluid  extract  of  digitalis  and  five  drops  of 
McMunn's  elixir  of  opium  may  be  given  every 
hour,  until  pulse  falls  to  75,  and  increases  in  size 
and  regularity.  Syncope  must  be  guarded  against 
instantly  and  hourly. 

0 


122  DISEASES   OP   THE   HEART. 

60.  It  will  rarely  be  found  necessary  to  bleed 
at  the  arm  at  all. 

61.  Leeches,  scarifications  and  cups  to  pre- 
cordia,  sinapisms  and  friction  to  the  joints,  a 
blister  around  each  knee  or  elbow  joint,  with  a 
brisk  and  certain  purge,  (calomel  fifteen  or  twenty 
grains  at  one  dose,  is  the  best,)  followed  by  saline 
diuretics,  combined  with  minute  doses  of  tartrate 
of  antimony  and  posassa,  (say  tlie  thirty-second 
part  of  a  grain  hourly,)  hot  bottles  to  the  loins 
and  feet.  Some  or  all  of  tliese  means,  or  others  on 
the  same  principles,  will,  in  most  cases,  be  found 
quite  sufiBcient  to  mitigate  the  attack,  and  con- 
duct the  disease  to  its  usual  result,  namely, 
termination  in  recovery. 

62.  It  is  very  rare  that  rheumatic  pericarditis 
or  endocarditis  treated  rationally,  or  let  alone, 
terminates  fatally  ;  but  it  is  altogether  probable 
that  the  worst  consequences — chronic  unsound- 
ness of  the  valves  from  endocarditis,  or  pericar- 
dial adhesions  from  pericarditis,  maybe  prevented 
altogether,  or  greatly  modified  by  rational  treat- 
ment. 

63.  In  the  nature  of  the  case,  this  theoretical 
probability  can  never  bo  demonstrated  ;  for,  if 
some  time  after,  a  case  of  marked  endo-pericar- 
ditis,  treated  rationally,  and  apparently  entirely 
cured,  should  die  of  some  other  aifeciion,  and  the 


THEIR   DIAGNOSIS   AND   TREATMENT.  123 

heart  should  be  found  intact,  it  would  not  follow 
that  the  treatment  had  saved  it ;  and  were  it  found 
chronically  diseased,  it  would  not  follow  that  the 
treatment  had  been  defective,  excessive  or  erro- 
neous. 

64.  But,  if  a  patient  of  mine  should  die  appa- 
rently of  rheumatic  pericarditis,  I  should  doubt 
my  diagnosis,  or  be  dissatisfied  with  the  energy 
or  rationality  of  my  treatment.  Not  so  with  the 
asthenic  forms  of  pericarditis  ;  these  are  much 
more  likely  in  their  own  nature  to  be  fatal  from 
the  beginning. 

65.  In  asthenic  rheumatism,  no  matter  from 
what  source  the  asthenia  springs,  pericarditis 
should  not  be  treated  antiphlogistically.  Car- 
bonate of  potash  and  of  ammonia  internally, 
counter-irritation,  good  nourishment  and  mode- 
rate doses  of  wine  or  brandy,  form  the  staple 
agents  of  treatment.     (Walshe.) 

66.  I  would  caution,  in  the  use  of  alcoholic 
stimulation,  to  watch  its  effects  constantly.  The 
pulse  should  not  be  carried  above  85  ;  on  the 
other  hand,  it  should  not  be  allowed  to  fall  below 
70.  It  can  be  maintained  in  these  limits  gene- 
rally, (except  when  the  pericarditis  accompanies 
renal  degeneration,)  with  small  doses  of  digitalis 
and  laudanum. 


124  DISEASES    OF   THE    HEART  : 

67.  Alkalies — bicarbonate,  of  potash,  liquor 
potassse,  are  tlieoretically  if  not  practically 
worthy  of  trial  in  very  large  doses  in  the  fibrin- 
ous diathesis,  especially  if  there  be  any  suspicion 
of  emboli  in  the  heart  or  arteries.  I  need  not 
say  these  remedies  are  to  be  largely  diluted. 

68.  If  a  stimulant  is  required,  carbonate  of 
ammonia,  or  aromatic  spirits  of  ammonia  and 
tincture  of  lavender  ^  may  be  given  in  conjunc- 
tion with  the  alkalies  (69). 

69.  The  enormous  doses  of  brandy,  a  pint  or 
more  a  day,  recommended  by  Todd  and  Bowman, 
are  repugnant  to  theory  and  prohibited  by  un- 
prejudiced clinical  experience,  a.  Can  any  one 
doubt  that  intoxication  induces  venous  congestion 
of  the  corronary  veins,  as  of  others  ? 

Can  any  one  doubt  that  congestion  of  the  heart 
and  lungs  increases  the  labor  of  the  heart  (al- 
ready requiring  alleviation,)  and  thus  diminishes 
its  dynamism  ?  Is  it  supposed  that  impaired 
dynamism  of  the  heart  is  conducive  to  the  restor- 
ation of  its  inflamed  serous  envelope  ? 

70.  It  cannot  be  denied  that  brandy  diminishes 
the  coagulability  of  the  blood,  and  thus  would  tend 
to  prevent  the  formation  of  intra-ventricular  clot 


*  Sp.  ammon.  aromat.  dr.  i ;  sp.  la  vend.  comp.  dr.  vij.  M. 
Sig.    Dose  a  teaspoonful  as  olten  as  required,  in  water. 


THEIR   DIAGNOSIS    AND    TREATMENT.  125 

in  endocarditis  ;  but  so  does  chloroform  diminish 
or  prevent  coagulability  ;  so  does  electricity  and 
many  poisons,  but  we  cannot  deduce  from  this 
one  fact,  their  therapeutic  utility. 

71 .  We  know  that  alcohol  given  in  large  doses 
to  sthenic  or  plethoric  patients  increases  their 
fever,  adds  to  their  irritability,  congests  the 
liver,  impairs  pulmonic  funqtions,  diminishes  the 
action  of  the  skin,  and  does  not  always  act  on 
the  kidneys  ;  that  it  impairs  appetite  and  assimi- 
lation ;  that  it  is  unquestionably  objectionable 
in  Bright^s  disease,  even  in  not  very  large  doses. 

72.  I  do  not  object  to  brandy  in  any  disease, 
but  I  cannot  help  thinking  that  it  ought  to  be 
used  in  much  smaller  quantities  in  acute  affections 
than  recommended  by  the  distinguished  authors 
just  mentioned. 

73.  Patients  with  any  form  of  organic  affec- 
tion of  the  heart  bear  brandy  very  indifferently, 
and  generally  object  to  it  very  strongly,  from  a 
firm  conviction  that  it  makes  them  worse.  Be- 
sides, in  organic  affections  of  the  heart,  acute 
or  chronic,  the  liver  is  rarely  exempt,  and  all 
drinkers  know  the  antipathy  of  this  organ, 
whenever  so  little  disturbed,  to  large  doses  of 
brandy  or  whiskey.  Soda-water  suits  it  much 
better. 


126  DISEASES    OF   THE   HEART  : 

74.  It  seems  to  me.  the  general  experience  of 
mankind  should  be  somewhat  regarded  in  refer- 
ence to  the  commonest  articles  of  daily  use,  and 
this  general  experience  is  opposed  to  excessive 
employment  of  the  hydro-carbons  in  acute  and 
inflammatory  diseases. 

75.  Recapitulation. — a.  The  treatment  of  peri- 
carditis and  endocarditis  is  nearly  the  same.  h. 
The  latter  is  more  injurious  in  its  consequences, 
and  hence  requires  more  care  in  treatment,  c. 
There  are  two  forms  :  the  sthenic  and  asthenic 
of  both  lesions .  d.  The  sthenic  is  treated  anti- 
phlofristically^  in  the  rational  sense,  by  which 
neither  salivation  nor  exhaustive  depletion  is 
understood  ;  that  is,  it  is  treated  with  aperients, 
watery  diuretics,  alkalies,  digitalis,  opium,  propy- 
lamin,  counter-irritation,  heat  locally  applied) 
local  depletion,  general  depletion  to  relieve  a 
pressing  need,  but  not  to  arrest  inflammation,  etc. 
e.  The  asthenic  is  treated  on  general  principles, 
specially  applied.  /.  Haematogens  —  beef-juice, 
egg-nogg,  vegetable  alkaloids,  bromide  of  potas- 
sium, perhaps  cod-liver  oil — counter-irritation 
and  frictions,  dry  cups  to  the  precordia,  arterial 
and  nerve  stimulants,  nutritious  diet. 

Mr.  Ure  (Braithwaite's  Retrospect,  vol.  1,  p. 
846,)  proposes  the  use  of  sulphate  of  manganese^ 


THEIR   DIAGNOSIS   AND   TREATMENT.  127 

not  omitting  but  supplementing  the  alkaline 
treatment  of  rheumatism,  to  prevent  it  attacking 
the  heart. 

M.  Gemlin  ascertained  that  this  remedy  aug- 
ments remarkably  the  secretion  of  bile,  and  it  has 
often  been  noticed  that  when  uric  acid  increases* 
bile  decreases,  and  visa  versa,.  Hence,  if  we  in- 
crease the  bile,  we  diminish  the  rheumatism. 
Mr.  Ure  recommends  a  drachm  of  this  sulphate 
to  be  dissolved  in  half  a  pint  of  water,  and  swal- 
lowed before  breakfast.  It  will  be  followed  by 
one  or  more  motions,  of  biliary  description. 

/.  This  remedy  is  worthy  of  trial  on  theoretical 
grounds,  especially  as  it  is  harmless. 

g.  Nitrate  of  potash  has  been  much  recom- 
mended, on  account  of  its  property  of  dissolving 
fibrin. 

h.  It  may  be  given  because  it  is  an  alkali,  to 
prevent  the  tendency  of  the  blood  to  become  acid, 
and  also  as  a  solvent  of  fibrin,  to  prevent  the 
precipitation  of  this  material  on  the  valves  of 
the  heart  and  other  portions  of  the  endocardium. 
It  is  probable  that  the  fibrinous  matter  found  on 
the  valves  of  the  heart  is  produced  both  from 
inflammation  of  the  lining  membrane  and  from 
precipitation,  when  it  is  in  excess  in  the  blood, 
and  when, the  circulation  is  very  much  impeded 


128  DISEASES   OF    THE    HEART  :'• 

or  very  much  slowed,  even  for  a  moment,  from- 
any  accidental  cause.  I  am  aware  that  stasis 
alone  will  not  induce  coagulation,  but  it  is  not 
denied  that  coagulation  is  thus  hastened,  under 
favorable  conditions.  ^ 

i.  Opium  is  often  needed  in  enormous  doses, 
to  produce  any  sensible  effect. 

j.  As  a  diuretic  in  pericarditis  in  Bright's  dis- 
ease, I  should  expect  great  benefit  from  gallic 
acid,  in  from  thirty  to  sixty  grains  at  a  dose  in 
as- much- water  as  the  patient  could  conveniently 
drink,  four  or  five  times  a  day.  The  hot-air  or 
vapor-bath  is  especially  recommended  as  a  sudo- 
rific in  this  variety  of  pericarditis,  because  it  can 
be'  administered  in  bed,  without  disturbing  the 
patient  and  without  raising  the  head,  which  often 
causes  great  prostration. 

k.  Purgatives  are  to  be  employed  with  great 
caution,  in  either  the  sthenic  or  asthenic  forms,' 
but  especially  in  the  latter.  Suphate  of  mag^" 
nesia  should  not  be  employed. 

76.  The  chronic  forms  of  these  lesions  are  to 
be  treated  on  general  principles,  it  being  under- 
stood that  they  can  be  alleviated,  but  not  cured. 

W.  For  example,  if  life  is  in  imminent  jeopardy' 


*  See  Appendix  H. 


THEIR    DIAGNOSIS    AND   TREATMENT.  129 

by  the  accumulation  of  fluid  in  the  pericardium, 
there  can  be  no  question  of  the  propriety  of  tap- 
ping near  the  base  of  the  heart,  upper  angle  of 
fourth  left  interspace,  and  re-injecting  a  small 
quantity,  of  equal  parts,  tincture  of  iodine  and 
distilled  water,  at  the  temperature  of  the  blood, 
before  removing  the  canula  of  the  trocar.  Iodine 
injections  are  recommended  by  Aran.  This 
iodine  liquid  has  been  proved  harmless  to  serous 
membranes  in  numberless  examples. 

a.  Seton  at  the  praecordia,  mercurial  inunction, 
iodine  ointment,  or  dilute  tincture  of  iodine  are 
seemingly  beneficial. 

78.  Blisters  applied  near  the  praecordia  might 
promote  absorption. 

79.  A  dry  nutritiojis  diet  and  diuretics  are 
recommended,  with  great  reason.  Iodide  of 
potassium  taken  internally  could  not  retard 
absorption  of  lymph  and  serum,  and  by  many  is 
supposed  to  materially  aid  this  process.  But  I 
have  never  observed  such  a  result  either  in  this 
or  allied  effusions. 

80.  Here  passive  exercise  in  the  open  air,  and 
even  sea  voyages  may  be  advised,  with  prospect 
of  alleviation  and  arrest  of  the  slow  inflamma- 
tory process.  The  trial  of  alkaline  springs  should 
be  made,  if  possible. 


130  DISEASES   OF   THE   HEART  : 

a.  It  should  be  borne  in  mind  that  the  prognosis 
as  to  fatality  is  more  serious  in  pericarditis  than 
in  endocarditis.  The  latter  is  rarely  fatal,  whereas 
the  former  terminates  in  death  with  sufficient 
frequency  to  have  induced  M.  Louis  to  estimate 
the  deaths  from  this  cause  at  one  in  six  of  the 
cases  attacked.  Walshe  had  seen  only  seven  or 
eight  fatal  cases  of  fatal  rheumatic  pericarditis. 
Death  rarely  occurs  in  pericarditis  *'  before  the 
tenth  or  twelfth  day."  It  may  occur,  however, 
within  thirty-six  hours,  or  be  postponed  some 
weeks. 

h.  We  have  also  chronic  forms  of  both  these 
affections,  but  from  what  has  been  already  said 
of  the  acute  forms. and  of  valvular  diseases,  the 
treatment  of  chronic  endocarditis  is  obvious,  and 
that  of  pericarditis  requires  but  mere  mention. 
The  hypertrophy  and  dilatation  of  the  left  ven- 
tricle attending  chronic  pericarditis  are  less 
serious  than  when  these  affections  are  the  result 
of  valvular  disease  ;  the  treatment  of  these  con- 
ditions of  the  heart  will  be  considered  in  a  sub- 
sequent chapter.  As  for  the  rest,  the  treatment 
is  to  be  directed  to  the  absorption  of  the  effused 
fluid,  and  to  fortifying  and  controling  the  action 
of  the  heart.  It  is  doubtful  whether  local  appli- 
cations to  the  prjBcordia  will  be  of  much  benefit, 
except  for  the  modification  of  reflex  symptoms  ; 


THEIR    DIAGNOSIS    AND    TREATMENT.         131 

but  most  of  the  discutient  class  of  unguents, 
tinctures  and  liniments,  as  well  as  blisters,  setons, 
cauteries,  etc.  are  still  recommended  as  of  possi- 
ble utility.  In  chronic  pericarditic  effusion, 
paracentesis  of  the  pericardium,  as  already  sug- 
gested, is  unobjectionable,  after  a  reasonable 
trial  of  other  remedies.  ♦ 

c.  Acute  and  chronic  endo-pericarditis  can  be  ap- 
preciated and  treated  by  the  principles  already 
suggested. 

d.  Acute  carditis  is  not  susceptible  of  diagnosis 
in  the  present  state  of  knowledge;  that  it  has  a 
real  existence  is  well  proven  by  post  mortem  ob- 
servation, but  it  has  no  known  clinical  signs  by 
which  it  can  be  discriminated  from  endo-pericar- 
ditis. Hence,  it  is  obvious  its  separate  treat- 
ment it  not  a  subject  of  rational  consideration. 
Fortunately  it  is  a  rare  affection.  Similar  re- 
marks are  applicable  to  the  chronic  form  of 
carditis, 

e.  Hemorrhage  within  the  proper  substance  of 
the  heart  does  occur,  but  we  have  no  diagnostic 
symptoms.  So  effusion  of  the  blood  into  the 
pericardium — hcemo-pericardium — and  under  the 
endocardium  —  hcemo-endocardium  —  are  without 
diagnostic  symptoms  of  any  value.     (Edema  of 


132  DISEASES   OF   THE  HEART  : 

the  heart  exists,  but  cannot  be  diagnosticated  in 
the  present  state  of  knowledge. 

/.  Hydro-pericardium  is  recognizable,  if  the 
dropsy  be  considerable  by  the  pyramidal  outline 
of  pragcordial  dullness,  the  same  as  in  the  effu- 
sion stage  of  ])iricarditis.  (The  apex  of  the  dull- 
ness being  aBove  its  natural  point,  and  rising  to 
the  second  or  perhaps  to  the  first  cartilage,  Avhile 
the  base  does  not  fall  proportionally,  indeed  not 
at  all,  but  remains  at  the  lower  margin  of  the 
sixth  rib.)  The  visible  impulse  is  undulatory, 
unless  the  effusion  be  slight.  A  sensation  of  op- 
pression at  the  praecordia  is  often  though  not 
always  felt ;  the  pulse  is  not  affected.  The  dropsy 
must  depend  on  some  altered  condition  of  the 
blood,  conjoined  with  some  other  organic  lesion  ; 
hence  the  general  symptoms  will  be  those  of  the 
subjacent  affection,  and  the  treatment  will  be  the 
same  as  that  of  other  dropsies,  though  diuretics 
and  cathartics  will  be  found  less  efficient.  Dry 
cupping,  blisters  and  electricity,  one  or  the  other, 
may  be  applied  at  or  near  the  praecordia  with 
considerable  hope  of  benefit. 

g,  Paracentisis,  and  subsequent  iodinized  in- 
3ections,  so  as  to  excite  adhesion  of  the  pericardial 
surfaces,  may  be  found  advisable  under  particular 
circumstances  ;  but  the  principal  hope   of  cure 


THEIR   DIAGNOSIS   AND   TREATMENT.  133 

lies  in  the  alleviation  or  removal  of  the  disease 
on  which  this  effusion  depends. 

h.  The  diagnosis  and  treatment  of  cases  in  which 
air  or  gasses  find  ingress  to  the  heart's  cavities 
or  beneath  its  membranes  cannot  be  rationally 
considered,  and  hence  the  treatment  must  be  sug- 
gested by  the  special  indications,  in  any  suspected 
case. 

i.  Cardiac  atrophy,  whether  limited  to  the  mus- 
cular walls  or  valves  of  the  heart,  is  clinically 
unrecognizable,  and  an  anatomical  curiosity,  and 
may  be  clinically  ignored. 

j.  Hypertrophy  of  the  valves  of  the  heart,  would,  at 
first  view,  seem  to  be  the  result  of  endocarditis, 
but  it  may  rationally  result  from  excessive  func- 
tion, and  consequently  excessive  nutrition,  as  a 
result  of  hypertrophy  pure  and  simple.  It  cannot 
be  recognized  clinically,  and  if  suspected  its 
treatment  is  merged  in  that  of  hypertrophy. 


184  DISEASES    OF   THE   HEART  : 

CHAPTER  Vm. 

Hypertrophy.    Dilatation. 

81.  Hypertrophy  \^  not  very  frequently  an  idio- 
pathic disease.  Like  dilatation,  it  is  generally 
the  outgrowth  of  some  previously  existing  lesion 
of  the  valves  or  vessels  proceeding  from  the  heart; 
of  some  impediment,  (as  of  a  tumor  or  a  consoli- 
dated lung,)  to  the  free  movement  of  the  heart. 

82.  It  may  be  caused  by  excessive  nourishment, 
too  free  living,  and  excessive  drinking,  excessive 
labor  in  which  the  strength  is  taxed  to  the  ut- 
most. Gymnasts,  stevedores,  furniture-movers, 
iron-moulders,  athletes,  all  furnish  examples  of 
pure  hypertrophy.  It  is  comparatively  rare  in 
females,  except  in  those  who  have  borne  many 
children. 

83.  Obstructions  in  the  lungs  would  cause  hy- 
pertrophy of  right  sooner  than  the  left  ventricle. 

84.  The  hypertrophy  attending  free  living  and 
sedentary  habits  is  apt  to  be  attended  with  fatty 
metamorphosis,  and  is  of  much  more  dangerous 
significance  than  hypertrophy  pure  and  simple 
from  excessive  function. 

85.  The  left  ventricle  is  by  far  the  most  fre- 
quently affected  ;  next,  the  left  auricle,  then  the 


THEIR   DIAGNOSIS   AND   TREATMENT.  135 

right  ventricle  ;  the  right  auricle  is  very  rarely 
hypertrophous. 

86.  Left  ventricle  in  a  hypertrophous  state  is 
recognized  by  praecordial  bulging,  widened  inter- 
spaces, heaving,  sustained  impulse,  when  the  side 
of  the  observer's  head  is  laid  over  the  heart  ; 
regular  rhythm,  force  of  impulse  unequal  ;  extent 
of,  increased  ;  maximum  of,  about  the  left  nipple. 

a.  Unless  there  is  associated  dilatation,  the 
apex  beats  will  rarely  extend  to  the  left  of  left 
nipple,  or  below  thq  seventh  rib.  h.  If  there  is 
dilatation  alsp,  the  apex  may  be  carried  much 
farther  beyond  the  nipple,  and  as  low  even  as  the 
eighth  rib.  c.  In  this  case  the  visible  impulse 
will  be  much  greater,  more  knocking,  heard  dis- 
tinctly and  clearly  some  indies  from  the  thorax  ; 
the  impulse  is  also  less  heaving  ;  the  heart  merely 
strikes,  without  raising  the  ribs  and  interspaces, 
and  the  whole  prsecordial  surface,  down  as  far  as 
to  the  left  of  and  below  the  left  nipple,  seems 
agitated  in  extreme  case  of  dilatation  with  hy- 
pertrophy. 

87.  In  the  case  I  have  in  mind,  Mrs.  D ,  of 

San  Francisco,  a  young  married  lady,  the  thump- 
ing  of  the  heart  could  be  heard  several  feet,  and 
the  appearance  of  the  impulse  was  that  of  the 
skin  over  the  emaciated  thorax,  being  raised  in 


136  DISEASES     OF   THE   HEART  : 

numerous  places  in  a  sort  of  undulating  rhythm, 
suddenly  and  a  hundred  and  twenty  times  a 
minute.  This  was  a  case  of  enormous  eccentric 
hypertrophy,  and  terminated  fatally  a  few  days 
after  my  first  and  only  visit. 

88.  Dullness  to  percussion  may  extend  from 
the  second  to  the  eighth  rib,  and  from  two  inches 
to  the  right  of  the  sternum  to  three  inches  out- 
side of  a  vertical  line  drawn  through  the  left 
nipple.  In  exceptional  cases,  "  the  percussion 
sound  may  be  toneless  and  high-pitched  all  over 
the  left  lateral  regions  of  the  thorax,  and  vocal 
fremitus  null,  just  as  if  pleural  effusion  existed." 
(Walshe.) 

89.  The  diagnosis  of  hypertrophy,  without  or 
with  marked  dilatatfon,  is  not  difficult,  a.  Be- 
sides the  percussion  and  auscultory  signs  men- 
tioned, there  is  in  hypertrophy  the  marked  symp- 
tom of  persistent  force  of  the  pulse. 

b.  The  pulse  may  vary  in  the  course  of  a  single 
day  from  65  to  110,  and  from  being  full,  hard 
and  resistant,  to  being  compressible,  full  and 
soft — rarely  irregular  or  intermittent  ;  and  when 
these  conditions  are  present,  other  lesions  exist 
in  the  heart.  c.  The  patient  will  be  strong, 
vigorous  and  full-blooded,  of  florid  complexion, 
and  apparently  robust  health,     d.  A  case  of  this 


THEIK   DIAGNOSIS   AND   TREATMENT.  137 

kind  now  on  my  mind  is  a  young  man,  aged  25, 
who  can  lift  six  hundred  pounds,  and  who  is  in 
the  habit  of  lifting  two  and  three  hundred  at  a 
time  daily. 

e.  The  strength  is  not  lessened,  but  the  dysp- 
noea becomes  intolerable,  from  prolonged  or 
excessive  exertion,  and  cough  supervenes. 

f.  The  patient  wants  his  head  tilted  forward 
when  he  sleeps,  rather  than  have  his  shoulder 
raised  with  his  head.  There  is  no  orthopnoea, 
but  the  liead  aches  if  lying  in  a  line  with  the 
trunk.  This  symptom  is  not  always  present. 
g.  The  varying  frequency  of  the  pulse  is  doubt- 
less exceptional  in  the  case  now  under  consider- 
ation, h.  There  is  no  dyspepsia,  but  little  pain 
in  the  heart,  but  more  or  less  uneasiness,  and  a 
sense  of  fullness  ;  frequently  dizzy  on  stooping  ; 
the  conjunctiva  habitually  red  ;  sleep  disturbed 
with  strange  dreams.  [In  this  case  the  symptom 
was  removed  by  thirty  grains  of  bromide  of 
potassium  daily,  at  bed. time.]  i.  No  increase 
of  sexual  desire  in  this  case,  as  has  been  supposed 
on  theoretical  grounds,  j.  There  is  a  systolic 
blowing  murmur  at  base  of  varying  loudness 
and  not  persistent.  When  the  heart  beats  with 
unusual  violence  the  murmur  is  very  distinct  ; 
when  "  slowed^'  and  subdued  with  digitalis,  it  is 

Q 


138  DISEASES   OF   THE   HEART  : 

inaudible,  /c.  I  suspect  this  murmur  is  not  rare, 
for  water  forced  through  a  tube  of  varying  cali- 
bre with  considerable  violence,  emits  a  murmur 
at  the  point  of  variation  in  the  diameter  of  the 
tube.  /.  The  extremities  do  not  swell,  nor  is 
there  ascites,  m.  In  this  case  there  is  frequent 
pain  in  the  right  side,  and  occasional  congestion 
of  the  liver,  n.  The  bowels  are  disposed  to  con- 
stipation ;  nutrition  and  hematosis  is  excellent. 
0.  There  is  no  lividity  of  the  nails,  or  ears,  or  lips; 
no  coldness  of  hands  or  feet,  except  occasionally 
some  hours  after  excessive  fatigue,  p.  Dilatation 
may  have  begun  in  such  a  case,  and  be  yet  so 
slight  as  to  be  overshadowed  by  the  hyper- 
trophy. 

90.  The  treatment  of  hypertrophy  is  directed 
to  the  retardation  of  the  disease,  probably  to  its 
arrest,  possibly -to  its  cure. 

91.  Few  physicianji  now  believe  in  the  cure  of 
hypertrophy.  "  On  the  other  hand,  it  is  not 
difficult  to  remove  or  greatly  mitigate  the  symp- 
toms of  simple  hypertrophy  in  the  majority  of 
cases,  and  render  life,  not  merely  tolerable,  but 
comfortable.'^ 

92.  The  heart's  action  is  to  be  quieted,  and 
the  amount  of  blood  diminished,  without  deterio- 
rating its  quality. 


THEIR   DIAGNOSIS   AND    TREATMENT.  139 

a.  I  have  elsewhere  (p.  61  passim)  shown  how 
this  may  be  done,  by  diminishing  the  weight  of 
the  body,  by  means  of  restricted  and  dry  diet. 
b.  The  heart  must  have  less  blood  to  impel,  but  it 
must  have  good  blood  for  its  own  sustenance,  or 
we  may  have  fatty  metamorphosis  added  to  our 
hypertrophy,  c.  The  patient  may  be  cupped  or 
leeched  at  the  prascordia  once  a  week,  if  neces- 
sary ;  purged  occasionally  ;  take  diuretics  most 
of  the  time — solution  of  perchloride  of  iron  and 
digitalis,  with  antimony — baths  every  other  day  ; 
plenty  of  passive  exercise,  until  he  is  made  quite 
comfortable,  and  all  severe  symptoms  are  re- 
moved, d.  If  the  hypertrophy  were  caused  by 
excessive  exertion  or  labor,  that  must  be  stopped, 
of  course  ;  if  by  excessive  eating  and  idleness,  a 
restricted  diet  and  some  exercise  must  be  en- 
joined, but  much  more  caution  in  depletion  will  be 
required  in  treating  this  class  of  cases,  than  that 
in  which  the  hypertrophy  results  from  excessive 
function  of  the  heart  i  tself. 

Case. — Mrs.  J.  S.  consults  me  concerning 
bronchitis.  She  has  taken  all  the  nostrums  and 
specifics,  has  been  relieved  often  ;  sometimes  has 
thought  herself  cured  ;  but  the  annoying  cough 
and  frothy  expectoration  returns  again  and 
again,  when  she  thinks  she  is  nearly  cured.    On 


140  DISEASES   OF   THE   HEART  : 

listening  at  the  prsecordia,  I  hear  a  systolic  mur- 
mur ;  move  my  ear  to  left  apex  and  it  is  much 
louder  ;  hearths  impulse  increased  in  extent  and 
vigor.  Apex  beat  farther  to  left  than  normal  ; 
the  head  is  lifted  by  the  throb  of  a  hypertrophied 
heart  ;  the  sounds  are  nearer  to  the  ear  and 
more  neatly  accented  than  normally.  She  has 
incompetent  mitral  valves,  dilatation  with  hyper- 
trophy, the  latter  still  in  excess  ;  turgescence 
of  lungs  from  refluent  current ;  mechanical  com- 
pression of  left  lung  from  enlarged  heart  ;  hence 
initative  cough,  with  increased  mucous  expecto- 
ration. 

Give  a  calomel  purge,  followed  by  syrup  of 
wild  cherry  and  tincture  of  aconite  ;  restrict 
diet  one  half.  In  three^  days  the  cough  has  dis- 
appeared, and  the  patient  feels  much  better, 
though  her  garments  fitting  less  snugly,  she 
"  fears  she  is  losing  flesh  f^^ 

She  is  losing  flesh,  and  must  never  again  carry 
so  much  flesh,  if  she  hopes  to  be  free  from  her 
*'  bronchitis."  This  is  one  case  of  a  whole  class 
in  which  loss  is  gain.  A  heart  which  will  utterly 
fail  to  impel  16  or  17  pounds  of  blood — the  nor- 
mal amount — will  get  along  with  14  or  15  pounds 
with  little  or  no  difficulty.  It  must  not  be  in- 
ferred from  this,  that  therefore  bleeding  to  the 


THEIR   DIAGNOSIS   AND    TREATMENT.  141 

amount  of  one  or  two  pounds  will  answer  the 
purpose  and  prove  beneficial.  The  weight  of  the 
body  must  b^  diminished  in  the  same  proportion. 
If  we  wish  to  abstract  a  pound  of  blood  from  a 
patient  with  dilated  heart,  we  must  do  so  by 
reducing  the  patient  eight  pounds  in  flesh,  by 
means  of  low  diet,  or,  in  cases  of  urgent  need,  by 
total  abstinence  from  food  until  the  effect  is  pro- 
duced, it  is  remarkable  how  soon  the  overtasked 
heart  will  recover  its  tone  when  the  patient  en- 
tirely abstains  from  food,  and  takes  small  doses 
of  some  nerve  sedative  to  quiet  the  irritability 
which  hunger  sometimes  induces.  The  pressure 
disappears  from  the  chest,  as  weight  diminishes, 
and  very*soon,  say  from  three  to  five  days,  the 
patient,  if  not  yet  in  the  dropsical  stage,  will  say 
he  is  better  than  ever,  and  that  he  scarcely  knows 
he  has  a  heart.  Even  now,  a  single  full  meal 
will  bring  back  all  his  consciousness  of  his  heart 
and  of  its  unnatural  condition. 

93.  Pure  and  simple  hypertrophy  is  not  apt  to 
destroy  life,  a.  It  is  only  when  other  organic 
diseases  have  come  on,  or  when  dilatation  be- 
comes excessive  that  life  is  in  jeopardy. 

94.  Dilatation  will  not  be  difficult  of  diagnosis, 
a.  This  has  already  been  given  to  some  extent 
(IF  89)  in  speaking  of  hypertrophy. 


14^2  .       DISEASES    OF   THE   HEART  : 

95.  a.  The  pulse  is  weak  and  irregular  in  force 
and  rhythm  ;  rarely  intermittent,  b.  Apex  beat 
indistinct  and  not  lowered  ;  percussion  dullness 
increased  vertically  more  than  transversely  ; 
impulse  undulatory  ;  ribs  not  bulged,  unless  there 
is  also  hypertrophy  ;  systolic  sound,  shorter, 
clearer  and  more  superficial  than  in  health  ;  de- 
fective nutrition  ;  dyspepsia  more  or  less  marked, 
dropsy,  especially  of  lower  extremities;  tendency 
to  emaciation  ;  cold  extremities  ;  feeling  of  being 
chilly  from  defective  circulation  ;  palpitation  on 
the  least  excitement;  great  praecordial  uneasiness; 
ringing  of  the  ears,  headache,  indisposition  to 
any  labor,  mental  or  bodily  ;  somnolence,  in  the 
advanced  stages  of  the  disease  ;  eviderK^e  of  con- 
gested liver  and  kidneys ;  sexual  inclination 
weakened  ;  superficial  pulses  not  visible  ;  symp- 
toms of  bronchitis  and  pulmonary  oedema  ;  in 
the  last  stages  of  the  disease,  orthopnoea  complete: 
asthmatic  paroxysms  ;  occasional  respiratory  for- 
getfulness,  a  fatal  symptom;  frequent  nausea  and 
anorexia  ;  livid  discoloration  in  spots;  occasional 
sphacelus  of  the  finger  tips  or  toes,  from  capillary 
stasis  ;  leaden,  almost  black  lips,  particularly  in 
the  morning. 

96.  Some  or  all  of  these  symptoms  may  be 
present  in  a  single  case,  a.  When  but  a  few  of 
them  are  present,  even  the  auscultatory  and  per- 


THEIR   DIAGNOSIS   AND    TREATMENT.  143 

cussion  signs  only,  the  diagnosis  is  established. 

97.  The  differential  diagnosis  of  hypertrophy 
and  dilatation  is  obvious  from  what  has  been 
already  said. 

98.  As  to  the  treatmeritj  it  is  radically  differ- 
ent from  hypertrophy.  a.  The  treatment  is 
eminently  sustaining,  directed  to  the  improve- 
ment of  the  quality  of  the  blood,  without  diminu- 
tion of  its  quantity  even,  for  it  is  not  likely  to  be 
in  excess. 

99.  Solution  of  perchloride  of  iron,  largely 
diluted,  is  here  of  special  service  as  a  diuretic 
and  tonic,  a.  Opium  and  quinine  combined  are 
constantly  required,  not  more  than  two  or  three 
grains  of  quinine  a  day  is  requisite.  It  may 
be  given  in  three  or  four  pills,  one  at  a  time,  each 
pill  to  contain  from  an  eighth  to  half  a  grain  of 
opium. 

b.  If  the  pulse  be  rapid,  above  90,  digitalis  may 
be  given  in  syrup  of  wild  cherry,  in  half  drop 
doses  hourly,  until  the  pulse  fall  to  85,  but  it 
must  be  given  with  greater  caution  than  in  any 
affection  of  the  heart,  except  fatty  degeneration. 

c.  The  bowels  may  be  moved  daily  with  any 
mild  aperient;  perhaps  formula  a,  page  59,  will  be 
found  convenient.  An  aloetic  pill  daily  at  bed- 
time, or  a  castor-oil  capsule  maj^  answer  as  well. 


144  DISEASES   OF   THE    HEART  : 

d.  Taraxacum  and  calomel  are  recommended 
for  the  same  purpose,  and  are  often  indicated. 

e.  Dry  cups  to  the  heart  in  case  of  extreme 
palpitation  or  anp^ina  often  afford  instant  and 
enduring  relief.  /.  Blood  must  rarely  be  taken. 
g.  Passive  exercise  is  of  great  utility,  h.  The 
patient  must  lead  a  cheerful  life,  and  not  be  ex- 
posed to  annoyances  and  hardships  ;  voluntary 
exercise,  such  as  walking  or  horseback  riding 
must  not  be  tolerated,  except  with  great  caution. 
No  violent  emotion  or  passion  should  be  indulged. 
('*  rupture  of  a  dilated  heart  has  occurred  in  actu 
coitus^)  Animal  diet  is  preferable  ;  much  drink 
of  any  kind,  even  if  it  be  milk,  is  to  be  avoided; 
the  diet  should  be  rather  dry  than  the  contrary, 
but  well  prepared  and  easily  digestible.  Cold 
sponge  baths  may  be  used,  if  they  agree  with  the 
patient,  not  otherwise.  Perhaps  tepid  or  hot 
salt  water  bathing  is  on  the  whole  the  best.  The 
clothing,  especially  of  the  extremities,  should  be 
warm  and  light;  intercurrent  diseases  must  be 
treated  on  general  principles  modified  to  suit  the 
actual  condition  of  the  heart. 

100.  Ammonia  and  lavender  will  afford  speedy 
relief  to  depressed  nervous  sensations,  and  prse- 
cordial  faintness.  a.  In  the  •latter  stages,  the 
patient  should  be  always  watched  in  sleep,  on 


THEIR    DIAGNOSIS     AND    TREATMENT.         145 

account  of  the  strong  tendency  to  respiratory  for- 
getfulness,  by  which  life  might  be  suddenly  ar- 
rested, long  before  the  necessary  fatal  issue  of  the 
disease.  I  will  close  the  consideration  of  dilata- 
tion by  a  condensed  abstract  of  a  peculiar  mode 
of  treatment  suggested  by  Piorry,  of  Paris,  in 
1858. 

101.  By  a  series  of  observations,  carefully 
made,  with  the  aid  of  the  plessimeter,  Piorry 
satisfied  himself  that  the  heart  and  liver  of  a  per- 
son in  health  diminish  in  bulk  by  forced  inspira- 
tions. He  next  undertook  to  apply  this  discovery 
to  the  diagnosis  and  treatment  of  enlarged  liver 
and  heart,  I  have  not  attempted  to  repeat  his 
experiments,  but  they  seem  rational,  and  the 
opinion  of  M.  Piorry,  who  has  applied  himself  to 
percussion  and  auscultation  for  now  nearly  forty 

*  years,  will  hardly  be  contradicted.     But  to  the 
facts. 

102.  M.  Piorry  selected  a  hysterical  patient, 
who  had  nothing  the  matter  with  either  the  heart 
or  liver  ;  he  limited  the  heart  by  percussion, 
and  found  it  occupied  a  space  of  11  centimeters  ^ 
from  right  to  left  ;  the  liver  occupied  a  space  of 
14  centimeters,  from  above  downward.  (I  omit 
the  other  measurements.)    This  done,  he  directed 


*  See  note  page  75. 


1^6  DISEASES   OP   THE   HEART  . 

the  patient  to  breathe  forcibly  twenty  times  in 
succession,  and  then  repercussed:  instead  of  11 
he  found  9  to  9|  for  the  heart ;  andinstead*of  14, 
about  12i  for  the  liver.  This  is  not  all.  He 
now  directed  the  patient  to  hold  her  breath, 
whereupon  he  demonstrated  that  the  two  organs 
named  not  only  returned  to  their  natural  di- 
mensions, but  that  they  slightly  increased  in  bulk. 

103.  Now,  as  this  experiment  has  had  the  same 
result  on  all  patients,  it  is  easy  to  see  its  influence 
upon  the  diagnosis  and  treatment  of  diseases  of 
these  two  organs. 

a.  What  is  said  above,  is,  moreover,  in  com- 
plete accord  with  what  is  daily  observed  in  path- 
ological anatomy.  Uniformly,  when  a  person 
dies  of  asphyxia  from  mucous  engorgement  of  the 
bronchi,  the  heart  and  liver  are  found  to  be  much 
enlarged  and  gorged  with  blood  ;  whereas,  on 
the  contrary,  when  the  respiration  is  unobstructed 
up  to  the  last  moment  of  life,  these  organs  are 
found  to  be  small  and  bloodless. 

104.  The  practical  applications  of  this  phe- 
nomenon are  the  following  :  It  aids  in  establishing 
the  diagnosis  :  a.  Of  hypertrophy  and  dilatation 
of  the  heart  ;  h.  Of  hepatemia  (congestion  of  the 
liver),  together  with  lesions  of  nutrition  of  this 
organ. 


THEIR    DIAGNOSIS   AND   TREATMENT.  147 

105.  It  aids  in  determining  the  rational  treat- 
ment of  dilatation  and  congestion  of  the  heart, 
and  ©f  some  of  the  organopathic  conditions  which 
are  the  consequences  of  these*  diseases. 

106.  Diagnosis  of  dilatation  and  of  hypertrophy 
of  the  heart.  Hitherto  we  have  had  but  little 
more  than  the  following  symptoms  by  which  to 
distinguish  dilatation  from  hypertrophy  of  the 
heart  :  more  extensive  dullness  at  the  praecordial 
region,  heart  beats  feeble,  absence  of  impulse  ;  if 
these  signs  were  perfectly  well  marked,  we  could 
establish  the  diagnosis  of  dilatation  beyond  ques- 
tion ;  but  in  the  majority  of  cases  there  was  room 
for  doubt  of  the  exactness  of  the  diagnosis  ;  but 
by  the  aid  of  the  physical  signs  I  am  about  to 
describe,  the  diagonsis  cannot  for  a  moment  re- 
main doubtful. 

107.  Let  us  suppose  two  well-marked  cases, 
one  of  hypertrophy^  the  other  of  dilatation  of  the 
heart.  Let  us  now  limit  the  volume  of  the  heart 
very  accurately,  by  the  aid  of  percussion  ;  now 
let  us  cause  the  patient  to  breathe  forcibly  several 
times  in  succession  ;  let  us  now  measure  the  heart 
again  with  the  same  accuracy  ;  we  shall  find  in 
the  case  of  hypertrophy  that  tlie  heart  has  under- 
gone no  change  ;  whilst  in  the  case  of  dilatation, 
we  shall  find  that  the  heart  has  returned  to  about 


148  DISEASES    OF    THE   HEART  : 

its  normal  volume,  (that  is,  to  a  transverse  mea- 
surement of  about  11  centimeters.) 

108.  If  it  be  a  case  of  partial  dilatation,  "or  a 
partial  hypertrophy^^  the  cavities  of  the  heart, 
only  the  dilated  cavity  will  return  to  its  normal 
state,  while  the  hypertrophied  ventricle  will  re- 
main unaltered  by  the  forced  respirations. 

109.  If,  as  most  frequently  happens,  the  dila- 
tation be  accompanied  with  hypertrophy,  the 
diagnosis  will  be  still  more  easy,  because  in  such 
case,  the  only  slight  diminution  of  the  increased 
volume  of  the  heart,  will  indicate  dilatation  with 
hypertrophy. 

110.  In  dilatation,  the  heart  diminishes,  by 
emptying  itself  of  the  blood  which  it  contains. 
A  long  time  ago,  Piorry  observed  that  after 
bleeding  a  patient  with  dilated  heart,  this  organ 
was  found  diminished  in  bulk. 

111.  The  application  of  this  same  principle  to 
diagnosis  of  congestions,  or  permanent  alterations 
in  the  volume  of  the  liver  is  at  once  obvious. 

112.  Treatment  of  dilatation  of  the  heart,  and  its 
consequences.  The  treatment  of  hypertrophy  or 
dilatation,  or  the  two  conjoined,  follows  directly 
from  the  means  of  diagnosis, 

113.  In  these  cases,  if  the  patient  be  made  to 
take  deep  inspirations  from  time  to  time,  (the  more 


THEIR    DIAGNOSIS    AND    TREATMENT.         149 

frequently  the  better,)  amelioration  of  the  symp- 
toms will  very  soon  become  manifest.  In  most 
cases,  especially  in  dilatation  with  hypertroph3'5 
the  cure  will  not  be  so  radical,  but  the  patient 
will  experience  great  relief,  and  by  the  disease 
being  thus  kept  stationary,  existence  may  be  pro- 
longed far  beyond  the  limit  it  would  otherwise 
only  reach.  Piorry  says  he  has  cured  or  relieved 
a  great  many  cases  by  these  extremely  simple 
means. 

The  resultant  dropsies,  also,  often  rapidly  dis- 
appear under  the  same  treatment.  This  is  equally 
applicable  to  similar  conditions  of  the  liver,  and 
to  the  serous  infiltrations  resulting  from  obstruc- 
tion to  the  portal  circulation.  It  is  only  by  the 
aid  of  the  plessimeter  that  these  nice  variations 
in  the  volume  of  the  heart  or  liver  can  be  made 
out. 

Whatever  one  may  think  of  this  mode  of  diag- 
nosis and  treatment,  it  is  certainly  worthy  of 
trial,  especially  as  it  is  in  the  last  degree  harm- 
less. 


150  DISEASES    OF   THE   HEART  : 

CHAPTER  IX. 

SoFTENiisG,  Fatty  Metamorphosis  or  Degeneration, 
OK  Fatty  Substitution  of  the  Heart.  Rupture 
OF  THE  Heart.    Cases. 

114.  The  diagnosis  of  softening  of  the  heart  is 
not  easy  nor  absolute.  This  affection  occurs  in 
consequence  of  adynamic  diseases,  typhus,  ty- 
phoid, diphtheria,  variola,  scarlatina,  etc.  ;  and 
it  results  from  diathetic  conditions  of  the  blood, 
in  which  the  quality  ef  the  fibrin  is  deteriorated, 
or  the  proportion  of  the  red  globules  is  dimin- 
ished, or  that  of  the  white  globules  increased,  as 
in  cyanosis,  purpura,  scurvy,  leucohaemia,  glyco- 
haemia  and  acute  phthisis. 

115.  The  heart  softens,  at  least  superficially, 
in  pericarditis,  and  throughout  the  thickness  of 
its  walls  in  carditis,  in  hemorrhagic  or  serous 
infiltration,  in  fatty  external  deposit  it  is  softened 
superficially,  and  in  fatty  degeneration  it  is  soft- 
ened in  portions  of  the  walls  of  one  or  both  ven- 
tricles or  auricles,  or  throughout  its  entire  sub: 
stance,  ventricles,  auricles,  valves  and  investing 
membrane.  The  detailed  analysis  of  these  con- 
ditions does  not  come  within  the  scope  of  this 
epitome. 

116.  What  I  wish  now  to  consider,  is  simple 


THEIR    DIAGNOSIS   AND   TREATMENT.  151 

softening  of  the  muscular  substance  of  the  heart, 
without  metamorphosis  of  its  histological  ele- 
ments. 

Can  this  kind  of  softening  be  verified  clinically 
and  exclusive  of  softening  from  fatty  infiltration 
or  fatty  degeneration  ?  T  think  this  question 
may  be  promptly  answered  in  the  negative.  Nor 
are  the  causes  of  the  different  varieties  of  soften- 
ing so  clearly  appreciable  that  we  may  with  great 
probability  infer  that,  in  a  given  case,  the  soften- 
ing is  or  is  not  attended  with  fatty  degeneration 
or  infiltration. 

Still  most  careful  observers  will  have  a  settled 
opinion  in  their  own  minds,  based  on  more  or 
less  satisfactory  reasons.  Indeed,  the  diagnosis 
of  softening,  as  distinguished  from  degeneration^ 
can  be  rationally  made  out,  and  that  too  with 
sufficient  nearness  to  constitute  a  basis  for 
rational  treatment, 

a.  For  example  :  a  young  adult  of  active  hab- 
its, and  accustomed  to  plain  food  and  to  total 
abstinence  from  alcoholic  drinks,  is  attacked  with 
typhoid  fever,  and  in  the  course  of  one,  two  or 
three  weeks  presents  the  symptoms  of  softening, 
viz.:  feeble,  irregular  pulse  ;  much  diminished  or 
absent  first  sound  of  the  heart  (there  being  no 
mitral  regurgitation);  heart's   impulse   invisible 


152  DISEASES     OF   THE    HEART  : 

at  times,  and  when  visible  unaltered  in  location  ; 
impulse,  also,  but  slightly  appreciable  to  the 
touch,  or  entirely  impalpable  ;  the  extremities 
presenting  a  leaden  hue  (all  valvular  diseases 
susceptible  of  exclusion)  ;  suppose  this  case  to 
have  prsecordial  uneasiness,  vrith  occasional 
transient  pains  in  the  vicinity  of  the  heart ; 
would  it  not  be  extremely  probable  that  he 
had  simple  softening  without  degeneration  or 
even  dilatation  ?  Yet  the  symptoms  and  phy- 
sical signs  are  undistinguishable  from  those  of 
degeneration. 

117.  In  such  case,  if  the  diagnosis  of  simple 
softening  were  correct,  the  patient  would  in  all 
probability  rex^over  within  a  period  of  from  six 
to  twelve  months,  under  the  use  of  tonics,  nutri- 
tious diet,  moderate  exercise,  both  passive  and 
active,' dry  frictions,  and  cold  or  tepid  sponge- 
baths,  morning  or  evening,  as  should  best  agree 
with  the  particular  case.  Such  a  case  might  be 
allowed  moderate  doses  of  whiskey  or  brandy,  or 
half  an  ounce,  three  times  a  day,  of  a  mixture 
composed  of  equal  parts  of  cod-liver  oil,  whiskey, 
and  syrup  of  wild  cherry  bark,  or  perhaps,  better 
still,  Guffroy's  cod-liver  extract. 

118.  Is  it  not  possible  that  the  cases  of  soften- 
ing of  the  heart  (supposed  fatty)  mentioned  by 


THEIR    DIAGNOSIS    AND    TREATMENT.  153 

Markham  (London,  I860,)  as  having  been  bene- 
fitted by  "  cod  liver  oil  in  combination  with  steel,'' 
were  subjects  of  softening  without  degeneration  ? 

119.  However  this  may  be,  we  would  hardly 
on  theoretical  grounds  give  cod-liver  oil  to  a 
case  with  fatty  heart;  and  we  should  be  extremely 
cautious  in  the  use  of  stimulants  ;  while,  in  a 
case  of  this  kind,  both  would  be  indicated  in 
reasonably  large  doses.  As  intimated  above, 
(115)  the  prognosis  in  softening — non-fatty — is 
very  favorable,  and  would  suggest  an  early  and 
complete  recovery. 

120.  The  diagnosis  of  fatty  degeneration,  though 
never  absolute  and  exclusive,  is  made  out  with 
so  much  rationality  as  to  be  practically  but  little 
less  than  demonstration. 

The  diagnosis  is  based  on  the  symptoms  already 
mentioned  (115  &,)  to  which  may  be  added  de- 
fective memory  of  recent  events,  inability  to 
perform  mental  or  bodily  labor  for  any  consider- 
able length  of  time;  in  bad  cases,  the  pulse  less 
frequent  than  the  systole  of  the  heart.  Respira- 
tory forgetfulness  is  often  observed  ;  dyspnoea  is 
not  unfrequent;  and  whenever  this  occurs,  the 
liver  habitually  congested,  rapidly  enlarges; 
relative  increased  sharpness  to  second  sound  of 
heart. 

8 


154  DISEASES   OF   THE  HEART  : 

121.  The  arcus  senilis  has  no  value  as  a  symp- 
tom of  this  disease,  except  in  so  far  as  it*is  in 
harmony  with  the  general  leaden  hue  of  the  nails, 
lips,  ears,  ete. 

122.  Syncope,  and  loss  of  consciousness  with- 
out fainting,  are  likely  to  occur  several  times  in 
the  slow  course  of  this  disease  ;  for  it  is  emi- 
nently a  chronic  affection,  lasting  from  a  few 
years  to  the  number  of  years  of  human  life. 

123.  Its  favorite  subjects  are  persons  of  luxu- 
rious and  epicurean  habits.  Persons  who  take 
no  exercise  and  drink  freely,  are  especially  liable 
to  this  form  of  softening. 

124.  Case. — G.  N.,  of  San  Francisco,  height 
5  feet  10  inches,  corpulent,  weight  170ft)s.,  single,- 
living  in  perfect  idleness  on  ample  income,  a  very 
free-liver,  aged  38.  Drank  more  than  usual  on  Feb. 
7th,  1867,  his  last  birth-day  ;  in  the  evening  fell 
in  a^fit.  On  coming  out  of  this,  a  few  hours  after 
he  fell  again,  but  quickly  recovered,  having  sus- 
tained no  injury  but  a  cut  in  the  skin  of  the 
occiput.      Fits  epilepti-form. 

125.  He  took  30  grains  of  bromide  of  potassium, 
repeated  every  six  hours  ;  had  several  good  naps 
during  the  night,  and  seemed  much  better  on  the 
morning  of  the  8th.  Before  night  signs  of  deli- 
rium supervened.     He  talked  clearly  of  all  mat- 


THEIR    DIAGNOSIS    AND   TREATMENT.         155 

ters  of  his  past  life,  told  anecdotes  with  clearness 
and  fluency,  but  could  not  remember  anything 
then  occurring,  from  one  minute  to  another  ;  did 
not  recollect  whether  he  had  eaten  or  drank,  or 
taken  the  medicine  ordered.  At  11  a.  m.,  8th,  no 
pulse  except  at  intervals,  then  exceedingly  weak  ; 
Tieart  beats  150  per  minute  ;  respiration  varying 
from  50  to  80  in  three  successive  minutes  ;  deli- 
rium very  mild  and  subjective  ;  heart's  impulse 
feeble.  The  apex  strikes  the  thorax  in  the  fifth 
interspace,  directly  under  the  left  nipple.  No 
murmurs  on  auscultation  ;  first  sound  of  the  heart 
exceedingly  feeble,  as  if  it  were  an  attempt  at  a 
contraction  which  it  was  unable  to  complete. 
The  second  sound  was  also  muffled,  or  defective 
in  accent.  Respiratory  murmur  good,  except 
where  the  left  lung  was  pushed  upwards,  and  con- 
densed by  the  enormous  liver.  My  diagnosis  Avas 
fatty  degeneration,  with  dilatation;  the  epilepti- 
form fits  resulting  from  defective  supply  of  arte- 
rial blood  to  the  brain,  in  consequence  of  heart 
disease;  also,  mild  delirium  tremens. 

9th.  11  A.M.  Heart  beats  140  ;  no  pulse  at 
wrist  ;  sweat  drenching  in  abundance,  but  not 
viscid  nor  cold.  Has  persistent  clonic  spasms, 
particularly  of  fingers  and  wrist  joints.  He  lies 
flat  on  his  back,  and  will  have  no  pillow  except 


156  DISEASES    OF   THE   HEART  r 

the  corner  of  one  to  raise  his  head  to  the  level 
of  his  body.  Bromide  of  potassium,  digitalis, 
whiskey  and  beef  juice  fail  to  produce  any  ame- 
lioration ;  by  the  advice  of  his  consulting  phy- 
sician, he  is  allowed  to  have  laudanum  in  such 
doses  as  are  usually  given  in  delirium  tremens, 
which  the  consulting  physician  believed  he  had," 
pure  and'  simple.  At  the  fifth  dose,  given  half- 
hourly,  he  was  asleep  ;  heart  beats  140,  no  pulse  ; 
respiration  32  ;  eyes  closed,  sleep  profound,  some 
stertor,  clonic  spasms  of  mouth  and  jaw,  pupils 
not  larger  in  the  shade  than  the  head  of  a  pin. 
One  hour  later,  that  is,  the  9th,  at  10  p.m.  he 
died  without  having  awoke.  His  respiration  was 
the  same,  32,  and  his  heart  beats  140  up  to  the 
instant  of  death.  His  heart  stopped,  not  grad- 
ually but  abruptly  and  finally  at  the  same  instant. 
There  was  no  final  convulsion. 

126.  Post  mortem  fourteen  hours  after,  in  the 
presence  of  several  distinguished  physicians. 
There  was  found  fatty  degeneration  of  heart  and 
liver.  Heart  increased  about  one-tliird  in  size. 
There  was  no  sign  of  inflammation  in  or  out  of 
the  heart ;  no  dropsy  ;  no  clots  in  the  heart  or 
vessels  ;  heart  pale  and  flabby  ;  both  sets  of 
valves  examined  with  care  and  found  perfect ; 
liver  extended  above  the  third  rib,  was  extremely 
friable  and  pale.    The  heart  was  very  soft,  being 


THEIR   DIAGNOSIS   AND    TREATMENT.  157 

easily  rubbed  to  a  pulp  between  the  thumb  and 
finger  ;  on  section,  it  presented  pale  fawn-colored 
spots  on  the  cut  surfaces  of  both  ventricles;  these 
were  more  distinct  than  on  the  surfaces  of  the 
heart  before  being  cut.  Examination  under  the 
microscope  showed  abundance  of  oil-globules  and 
amorphous  pale  muscular  substance,  but  few 
striated  fibrillar.  Externally  the  heart  was  not 
encumbered  with  more  than  the  usual  amount  of 
fat,  and  this  was  principally  about  the  base  of 
the  right  ventricle. 

This  man  never  knew  he  had  any  disease  of 
the  heart,  but  had  complained  of  oppression 
about  the  pra)cordia  before  the  7th  Feb.,  and  had 
told  a  friend  he  was  going  to  have  his  heart 
examined  some  day,  soon.  An  opiate  in  large 
doses  is  the  very  worst  drug  that  can  be  given 
in  degeneration.  In  this  case  it  is  not  probable 
that  it  hastened  the  fatal  result,  for  the  case 
would  have  died  in  a  few  hours  more,  in  convul- 
sions, had  the  nervous  system  been  left  to  itself; 
but  it  is  observed  that  it  diminished  respiration 
(from  an  average  of  65  to  32)  without  affecting 
the  heart  beats,  which  was  equivalent  to  increas- 
ing the  dyspnoea  ;  the  dyspnoea  increased  the 
congestion  of  the  liver  and  the  engorgement  of 
the  hearths  cavities. 


158  diseases  of  the  heart 

127.  Case  of  Rupture  of  the  Heart  ;  Fatty 
Softening  ;  Dilatation. — Q.,  died  suddenly.  The 
autopsy  revealed  the  following  facts  :  The  begin- 
ning of  aorta  was  atheromatous  ;  the  right  cor- 
onary sinus  v/as  converted  into  an  aneurismal 
sac  the  size  of  a  hen's  egg.  The  coats  of  the 
artery  were  so  lar  ruptured  on  the  anterior  part 
of  the  sac,  that  ecchymosis  was  visible  under  the 
external  serous  covering.  This  rupture  was  in- 
complete, and  about  the  size  of  the  little  finger 
nail.  There  was  also  rupture  of  the  apex  of  left 
ventricle,  through  the  ventricular  wall  which  at 
this  point  was  not  a  line  in  thickness.  The  rup- 
ture was  incomplete,  like  that  of  the  aneurismal 
sac,  extending  only  to  the  viceral  layer  of  peri- 
cardium, which  was  glossy,  and  exhibited  no  sign 
of  inflammation.-  No  blood  had  escaped,  either 
from  the  aneurismal  sac,  or  the  apex  of  ventricle 
under  the  pericardium.  There  was  a  faint  attempt 
at  reparation  in  both  places,  shown  by  the  depo- 
sition of  lamince  of  fibrin,  but  this  attempt  had 
evidently  been  quite  abortive  ;  the  deposited 
laminae  were  almost  black,  and  dirty  looking. 
The  place  of  rupture  of  the  ventricle  was  indi- 
cated externally  by  the  ecchymosis  seen  through 
the  pericardium.  The  heart  was  full  twice  the 
normal  size,  very  soft,  and  evidently  degenerated, 
by  the  sub^tit.ition  of  fat  for  sarcous  elements. 


THEIR    DIAGNOSIS   AND   TREATMENT.  159 

Mitral  valves  incompetent ;  aortic  valves  perfect  ; 
the  other  valves  were  not  examined.  The  subject 
was  a  quadroon,  aged  30,  fine-looking,  not  ema- 
ciated. The  pleural  sac  and  peritoneum  were 
distended  with  effusion  ;  the  liver  was  much 
enlarged,  the  lungs  healthy.  There  were  several 
chafes  of  pleuritis,  with  deposition  of  lymph,  on 
the  mural  layer  of  pleura,  near  the  apex  of  the 
left  lung,  posterior  aspect. 

128.  This  was  a  case  of  sudden  death.  The 
f)ost  mortem  reveals  the  proximate  cause  to  have 
been  rupture  of  the  left  ventricle.  The  rupture 
occurred  in  consequence  of  dilatation,  conjoined 
with  degeneration  of  structure  elements.  The 
aneurismal  incomplete  rupture  was  also  much 
aided  by  4he  fatty  degeneration  of  the  aortic 
walls. 

129.  Violent  traumatic  rupture  of  the  heart, 
even  when  the  laceration  is  very  extensive,  does 
not  necessarily  cause  instant  death,  not  even 
fainting.  Morel-la-Vallce  saw  a  case  in  detail 
at  the  hospital  of  St.  Anthony,  Paris,  in  1858.  A 
man  of  sixty  was  thrown  from  an  omnibus,  a 
wheel  of  which  ran  over  his  chest,  crushing  it  in 
a  frightful  manner.  He  was  immediately  carried 
into  the  hospital  in  front  of  which  the  accident 
occurred.     Although  in   a   dying   condition,  he 


160  DISEASES   OF   THE   HEART  . 

made  some  signs  to  his  wife,  who  was  with  him, 
breathed  a  few  times,  but  was  pulseless,  and 
expired.  On  examination,  the  left  ventricle  was 
lacerated  the  whole  length  of  its  anterior  aspect; 
the  upper  part  of  the  septum  of  the  ventricles 
and  the  left  auricle  were  also  torn  completely 
through  ;  the  mitral  valve  was  torn  in  pieces,  the 
tendinous  cords  were  torn  out,  and  remained 
hanging  to  the  shreds  of  a  fleshy  column. 

130.  The  injury  to  the  heart  appeared  to  result 
from  excessive  pressure.  Although  the  sternum 
and  ribs  were  much  fractured,  no  osseous  frag- 
ment corresponded  with  any  rent  of  the  heart. 

131.  This  case,  though  not  properly  within  the 
scope  of  my  subject,  is  interesting  in  a  physiolo- 
gical point  of  view,  as  showing  what  extensive  in- 
jury the  heart  itself  may  sustain  without  causing 
instantaneous  death,  or  even  loss  of  consciousness. 
But  to  return  to  my  subject— fatty  heart — is  recog- 
nized with  great  difficulty  ;  but  tlie  most  reliable 
negative  symptom,  is  the  absence  of  dropsy.  The 
most  reliable  positive  symptoms  are,  liability  to 
"  heart  faintness"  and  intermittent  pulse,  while 
the  systoles  of  the  ventricles  are  regular  and  7iot 
intermittent.  In  the  advanced  stage  of  fatty 
degeneration — and  this  is  the  stage  in  which  our 
attention  is  most   frequently  called  to   it — this 


THEIR   DIAGNOSIS   AND   TREATMENT.  161 

symptom  of  pulse  weak  or  absent,  out  of  propor- 
tion to  the  systoles,  is  nearly  always  present. 
There  is  another  marked  symptom  in  this  stage  ; 
that  is,  a  muffled  toneless  first  sound,  quite  distia- 
guishable  from  the  accented  sound  from  dilatation 
without  degeneration,  and  also,  relatively  higher 
toned  and  more  accented  second  sound.  Precor- 
dial uneasiness  or  distress  is  also  a  marked  and 
frequent  symptom. 

132.  Summary  of  Treatment , — There  is  scarcely 
a  doubt  that  fatty  degeneration  may  be  arrested, 
and  that  the  unaffected  portions  of  the  heart  may 
be  so  far  fortified  as  to  perform  the  work  of  a 
sound  organ,  so  that  its  deficiencies  will  cause  no 
suffering,  or  even  uneasiness,  to  the  subject.  This 
amelioration  can  be  brought  about  by  hygienic 
and  medicinal  means  in  many  cases. 

133.  The  hygienic  means  are  frequent  bathing 
— twice  a  week — pure  air  night  and  day;  uniform 
temperature  of  the  surface  of  the  body,  by  light, 
warm  clothing,  passive  exercise  in  salubrious  dis- 
tricts of  country;  such  as  carriage,  boat  and  horse- 
back riding  ;  little  or  no  benefit  from  walking 
need  be  expected.  Food  should  be  nutritious 
and  easily  digested.  Fish,  meat,  game,  and  a 
rather  limited  amount  of  vegetable  food  may  be 
allowed.  Less  fatty,  starchy  or  saccharine  matter 
should  enter  into  the  diet  than  in  other  diseases, 


162  DISEASES    OF   THE   HEART  : 

except  there  be  good  reason  to  believe  that  the 
softening  of  the  heart  is  non-fatty.  All  alcoholic 
beverages  should  be  avoided,  except  for  the  im- 
mediate feeling  of  faintness.  All  sudden  excite- 
ments, or  causes  of  emotions^  should  be  avoided 
vrith  great  care. 

134.  The  most  relioble  medicinal  remedies  are 
solution  of  ]  erchloride  of  iron,  largely  diluted — 
a  drop  to  a  drachm  of  water — strynchia,  brucia, 
arsenic.  *  Quinine  and  opium  are  not  to  be  for- 
gotten (see  page  63,  c.)  ;  aloetic  pills,  or  some 
equivalent,  are  required  from  time  to  time,  or 
formula  a,  (page  57,)  may  be  employed  with  ad- 
vantage. Electro-magnetism,  of  very  low  tension, 
applied  over  the  pneumogastric  nerves,  or  over 
the  heart  itself  is  worthy  of  trial.  I  have  no 
experience  of  its  eJBfects  in  these  cases,  but  theo- 
retically believe  it  must  be  beneficial,  if  applied 
once  or  twice  a  day,  with  great  caution,  for  many 
months.  The  use  of  it  for  a  few  times  could  have 
no  result. 

135.  Finally:  fatty  heart  is  very  frequent  in 
this  city,  and  has  proved  fatal  in  many  instances 


*  Of  all  the  preparations  of  arsenic,  that  first  recom- 
mended by  Athar  Ali  Khan,  of  Delhi,  is  most  used  by  me. 
R.  White  arsenic,  grains  2  ;  black  •  pepper,  grains  100.  M. 
Make,  according  to  art,  into  sixty  pills.  S.  Dose,  one  a  day 
for  a  week,  and  finally  three  a  day  indefinitely. 


THEIR   DIAGNOSIS   AND   TREATMENT.  163 

within  my  own  observation.  It  favors  the  form- 
ation of  clots  in  the  heart — a  cause  of  sudden 
death.  In  almost  all  cases  of  rupture  of  the  heart, 
without  external  violence,  fatty  degeneration  is 
the  predisposing  cause — all  cases  of  rupture  die 
within  a  few  moments. 

136.  It  is  one  of  the  diseases  of  the  heart  that 
may  be  treated  with  the  most  rational  hopes  of 
amelioration  and  indefinite  prolongation  of  life, 
if  recognized  and  treated  before  it  has  become 
complicated  with  excessive  dilatation,  or  before  it 
has  reached  that  stage  in  which  the  pulse  is 
irregular,  very  weak,  tremulous  and  intermittent 
at  the  wrist,  before  fainting  fits  are  frequent ;  in 
short,  before  the  greater,  instead  of  the  less  por- 
tion of  the  heart  has  undergone  fatty  substitution. 
In  this  last  stage,  any  treatment — the  most  ra- 
tional— can  barely  alleviate  temporarily,  without 
the  slightest  hope  of  retarding  the  onward  pro- 
gress of  the  disease. 

137.  Angina  Pectoris,  or  '*  sujffocative  breast 
pang,"  is  a  disease  from  which  the  poor  are 
usually  exempt.  It  attacks  about  nine  males  to 
one  female.  It  scarcely  ever  occurs  before  the 
fortieth  year,  seldom  before  the  fiftieth.  It  is 
usually  protracted  in  its  course.  Death  lias  been 
known  to  follow  within  two  hours  of  the  first 


164  DISEASES    OP  THE   HEART  : 

attack  in  a  patient  aged    74.     (Latham.)    The 
average  duration  is  unknown. 

138.  No  disease  of  the  heart  is  more  certainly 
recognizable  than  angina  pectoris.  It  consists  of 
spasm  and  pain  in  the  breast,  generally  about  the 
lower  portion  of  the  sternum,  but  sometimes  as 
high  as  the  upper  end  of  this  bone.  The  pain 
runs  through  the  breast  to  the  back,  and  down 
the  left  arm.  There  is  a  sense  of  suflocation, 
and  a  feeling  that  death  is  imminent.  This  feel- 
ing of  speedy  dissolution  is  never  wanting,  any 
more  than  the  pain,  the  suffocation  and  the  con- 
striction about  the  heart.  It  comes  suddenly, 
without  warning,  and  goes  suddenly  and  com- 
pletely. A  patient  of  mine  was  walking  in  the 
street;  all  at  once  he  dropped  down  on  the  pave- 
ment, with  intense  tearing  pain,  and  a  feeling  of 
suffocation  and  instant  death.  He  immediately 
arose,  before  two  gentlemen  near  him,  who  sprang 
to  his  assistance  had -time  to  reach  him.  For  an 
instant,  he  says,  he  must  have  been  unconscious, 
%r  he  does  riot  remember  falling,  but  was  con- 
scious while  getting  up.  The  gentlemen  who 
wished  to  help  him  asked  how  he  came  to  fall  so 
suddenly  and  get  up  instantly.  He  answered 
that  he  did  not  know,  and  asked  how  long 
he  had  been  down  ?     They  replied,  ''  No  time  at 


THEIR    DIAGNOSIS    ANJ)    TREATMENT.         165 

all ;  3^011  got  up  as  soon  as  you  fell,  before  wo 
could  get  to  you.-'  This  man  has  had  no  attack 
since,  but  by  my  advice  lie  has  arranged  his 
affairs.  A  paroxyir^^m  of  angina  pectoris  may  last 
several  minutes  ;  that  this  was  a  case  in  which 
material  unsoundness  of  the  heart,  its  valves  and 
of  the  thoracic  aorta  were  present  is  indubitable, 
from  examinations  carefully  made,  previous  and 
subsequent  to  his  fall. 

139.  In  order  to  appreciate  the  manner  of 
diagnosis  J  it  is  proper  to  glance  at  the  usual 
pathological  condition  of  the  heart  in  fatal  cases, 

a.  In  almost  all  cases,  the  heart  walls,  espe- 
cially of  the  right  ventricle  are  thinned.  The 
heart  is  usually  softened,  generally  by  fatty  meta- 
morphosis. Neither  clots  in  the  heart  nor  em- 
boli in  the  arteries  have  been  found.  The  cor- 
ronary  arteries  are  frequently  more  or  less  ossified 
or  constricted  by  atheromatous  deposits.  JYo 
matter  what  the  cadaveric  rigidity  may  be,  the 
ht  art  will  always  be  found  soft;. 

140.  The  pain  of  angina  is  neuralgic,  not  that 
of  tenderness.  It  depends,  then,  on  lack  of  sup- 
ply of  red  blood  to  the  heart  itself,  or  upon  im- 
paired nutrition  or  irritation  of  that  branch  of 
tlie  vagus  which  supplies  the  heart. 

Any  cause  which  will  have  the  effect  of  tem- 


166  DISEASES   OP   THE   HEART  : 

porarily  diminishing  the  supply  of  arterial  blood 
to,  or  retard  the  return  of  venous  blood  from  the 
heart;  or  any  cause  which  shall  impair  the  nor- 
mal function  of  the  vagus  may  produce  a  paroxysm 
of  angina  pectoris.  No  causes  could  be  more  likely 
to  induce  such  defect  of  blood  supply  to  the  heart 
than  fatty  metamorphosis,  or  dilated  heart,  or  nar- 
rowed corronary  arteries — the  three  precise  con* 
ditions  in  which  we  find  angina  most  likely  to 
occur.  Here,  for  the  hundredth  time,  theory  and 
fact  coincide. 

141.  We  may  expect  in  most  cases  of  angina 
pectoris  a  feeble,  small  and  over  frequent  pulse, 
as  in  dilatation;  but  from  the  pulse  alone  nothing 
can  be  determined  in  this  affection.  The  diagnosis 
rests  entirely  on  the  character — the  unmistakable 
character  of  the  paroxysm — great  dread  of  death, 
a  feeling  of  inability  to  breathe,  for  fear  of  hurt- 
ing the  heart,  or  causing  death,  more  than  a 
conscious  ness  of  real  inability  to  take  a  full  in- 
spiration. 

The  Treatment  of  the  attack  itself  is  not  often 
committed  to  the  physician,  because  it  is  over 
before  he  arrives  ;  but  in  protracted  paroxysms, 
or  in  those  of  frequent  recurrence  in  the  same 
day  he  may  be  present. 

142.  Dry  cups  to  the  praecordia  afford  the  most 


THEIR    DIAGNOSIS    AND    TREATMENT.  167 

prompt  relief.  Stimulants,  in  small,  often  re- 
peated  doses,  should  be  given  at  the  same  time, 
if  the  patient  can  swallow.  A  touch  of  the 
cautery  between  the  shoulders,  will  undo  the 
spasm  of  the  heart  most  promptly.  If  the  stomach 
is  full,  it  should  be  relieved  by  a  prompt  ^emetic 
— sulpliate  of  zinc  or  powdered  ipecac,  a  large 
dose  in  a  goblet  of  tepid  water.  If  the  patient 
be  of  full  habit,  and  if  it  be  known  that  the  heart 
is  not  dilated,  and  if  serious  fatty  degeneration 
be  not  suspected,  ard  if  the  pulse  be  nearly  natural 
in  size  and  fullness  and  not  slow,  bleeding  at  the 
arm  is  certainly  indicated,  or  blood  may  be 
taken  by  scarification  and  cups  from  the  prae- 
cordia,  if  not  thought  proper  to  risk  the  open- 
ing of  a  vein. 

143.  But  the  most  important  part  of  the  treat- 
ment of  a  subject  of  angina  pectoris  is  that 
directed  to  the  postponing  of  the  recurrence  of 
the  attack,  which  is  sure  to  come  again,  sooner 
or  later,  and  with  more  violence  ;  and  the  more  v 
frequently  the  greater  the  number  of  paroxysms 
already* endured.  All  emotional  influences  must 
be  avoided.  The  temper  must  be  controlled. 
The  passions  indulged  with  the  greatest  modera- 
tion. The  natural  calls  of  the  body  obeyed  with 
deliberation  ;  hence  the  bowels  must  not  become 


168  DISEASES   OF   THE   HEART  : 

costive,  nor  the  bladder  distended.  There  must 
be  no  violent  or  forced  work,  or  exercise,  or 
amusement.  No  severe  or  rapid  intellectual  labor; 
no  excesses  of  any  kind — moral,  esthetic,  phy- 
sical, mental  or  emotional.  Daily  passive  exer- 
cise in^  the  open  air  ;  slovr  walking  on  level 
ground  in  open  spaces,  as  in  the  country  or  sub- 
urbs, or  unfrequented  streets,  may  be  permitted. 

144.  Riding  in  a  carriage  is  much  preferable 
to  riding  on  horseback,  however  easy  the  gait  of 
the  animal,  because  of  the  labor  of  mounting 
and  dismounting,  and  the  risk  of  sudden  motions 
of  the  horse,  which  might  bring  on  a  fatal  par- 
oxysm. 

Tonics  are  generally  indicated,  also  stimulants 
and  nitrogenous  nutrients,  in  rational  quantities. 
If  anemia  be  present,  iron  must  be  employed,  and 
cod  liver  oil,  in  the  modes  already  stated,  as  in 
dilatation,  or  in  softening,  without^  fatty  meta- 
morphosis. 

145.  Dr.  Walshe,  with  great  theoretical  prop- 
riety, says,  "  The  removal  of  gout,  chronic  rheu- 
matism, or  old  standing  skin  diseases,  should  be 
very  cautiously,  if  at  all  attempted,  in  the  subject 
of  angina  ;  relief  of  those  complaints  is  unques- 
tionably sometimes  followed  by  increased  severity 
of  the  cardiac  affection.^' 


THEIR    DIAGNOSIS    AND   TREATMENT.         169 

146.  Rheumatism^  which  occupies  so  important 
a  place  in  the  consideration  of  pericarditis  and 
endocarditis,  requires  mere  mention.  It  is  justly 
dreaded  on  account  of  the  occult  effects  it  is 
likely  to  leave  in  the  organism.  Persons  who 
had  rheumatism  years  ago,  are  constantly  seek- 
ing medical  advice  for  some  trouble  about  the 
heart,  although  at  the  time  of  the  rheumatism  no 
heart  symptoms  were  observed.  Is  it  not  pro- 
bable that  some  lesions  of  the  heart,  though  not 
derived  from  rheumatism  result  from  similar 
diseased  aetion,  or  from  the  presence  in  the 
blood  of  similar  morbific  elements  ? 

147.  I  will  assume  that  rheumatism  is  recogni- 
zable by  all  physicians,  and  will  merely  allude 
to  what  appears  to  me  to  be  two  well-marked 
varieties  of  this  affection.  The  one  I  will  call 
inflammatory  rheumatism,  which  is  most  to  be 
dreaded,  as  to  its  effects  on  the  heart ;  the  other 
I  will  call  neuralgic  rheumatism.  The  former  is 
attended  with  fever,  tenderness  and  acute  pain  and 
immobility  of  the  muscles  and  joints  implicated. 
The  latter  is  recognized  by  a  persistent  dull 
ache,  increased  to  an  ache  with  partial  numb- 
ness, by  excessive  use  of  the  affected  limb  or 
part,  but  never  attended  with  those  flashes  of 
agony  which  characterize  pure  neuralgia.     This 


170  DISEASES    OF   THE   HEART  ; 

kind  of  rheuraatism  is  certainly  curable  in  the 
great  majority  of  cases  with  quinine  and  opium 
in  combination,  given  in  small  doses,  aided  by 
colchicum  and  whiskey  given  in  regular  doses 
and  in  mixture.  Alcoholic  beverages  are  to  be 
avoided  ;  vinegar,  sugar  and  fruits  must  not  be 
used.  If  there  is  anemia,  cod-liver  oil,  with  syrup 
of  wild  cherry  and  whiskey  will  hasten  the  cure. 
From  one  to  six  months  of  this  treatment  will  be 
required,  in  neuralgic  rheumatism  of  the  hip 
joint  after  gonorrhoea,  or  in  neuralgic  rheuma- 
tism of  the  lumbar  region,  or  of  the  shoulders,  or 
feet  and  ankles. 

148.  Acute  or  chronic  inflammatory  rheuma- 
tism is  certainly  curable  in  a  great  majority  of 
cases  by  propylamin  and  laudanum,  and  aloetic 
aperients.  But  I  am  of  the  opinion  that  it  will 
often  be  found  requisite  to  give  ten  times  the 
dose  recommended  by  Dr.  Awenarius,  who  first 
recommended  it  in  this  disease.  I  have  cured  so 
many  cases  with  these  means  alone,  that  I  now 
use  scarcely  anything  else.  I  have  had  no  suc- 
cess with  stimulants,  nor  with  fatty  food.  Here, 
as  in  neuralgic  rheumatism,  vinegar,  sugar,  fruits, 
fermented  beverages,  etc.,  are  not  tolerated,  ex- 
cept there  be  anemia  as  a  complication. 

149.  Leeches    afford  temporary    relief,  so   do 


THEIR   DIAGNOSIS   AND    TREATMENT.  171 

stimulating  liniments,  and  anodyne  cataplasms; 
indeed,  moist  heat,  no  matter  how  applied,  so 
that  the  air  is  excluded  from  the  affected  part. 
Cathartics  and  small  bleedings  are  no  doubt 
often  of  great  benefit  in  the  beginning  of  the 
affection,  if  the  patient  be  of  full  habit  and  in 
good  blood-making  condition  ;  but  after  the  first 
few  days,  bleeding  is  worse  than  useless.  The 
aloetic  pills,  on  the  other  hand,  may  be  continued 
during  the  whole  course  in  laxative  doses. 

150.  Absolute  rest,  in  an  apartment  of  uniform 
and  rather  high  temperature  materially  hastens 
the  cure.  The  diet  should  consist  of  rather  thin 
broths,  with  plenty  of  salt  and  no  pepper.  No 
other  alkali  than  the  propylamin  will  be  needed. 

The  sulphate  of  manganese,  already  mentioned, 
I  have  no  experience  in,  but  it  is  well  worthy  of 
trial  as  a  preventive  of  the  cardiac  effects  of 
rheumatism. 


172  DISEASES   OF   THE    HEART  : 

CHAPTER  X. 

Thoracic  Aneurisms:  Diagnosis  and  Treatment. 
Cynosis  and  Atelectasis. 

151.  The  anatomical  relations  of  the  g;reat 
blood  vessels  of  the  chest  render  the  diseases  of 
these  structures  most  dangerous  in  their  ten- 
dencies and  results. 

152.  Under  the  head  of  thoracic  aneurism 
may  be  comprehended  aneurism  of  the  aorta,  or  of 
the  innominata,  pulmonary  or  bronchial  arteries. 
The  diagnosis  of  thoracic  aneurism  in  its  earlier 
stashes  is  always  difficult  and  frequently  quite 
impossible  ;  for  although  its  presence  is  always 
attended  with  more  or  less  objective  and  subjec- 
tive symptoms,  still  there  is  no  known  pathogno- 
monic indication  upon  which  we  can  place  im- 
plicit reliance.  As  the  tumor  progresses  in 
growth,  and  fluctuation  and  pulsation  become 
evident,  of  course  there  can  no  longer  remain 
any  doubt  as  to  the  nature  of  the  disease.  The 
diagnosis  of  aneurism  of  the  aorta  will  be  aided 
by  a  consideration  of  the  mechanical  effects  such 
an  enlargement  might  be  expected  to  produce, 
and  also  the  peculiar  functional  disturbances 
which  would  most  likely  ensue  from  the  conse- 
quent pressure  upon  surrounding  and  adjacent 
structures. 


THEIR    DIAGNOSIS   AND    TREATMENT.  173 

153.  Thus,  if  a  patient  present  no  satisfactory 
evidence  of  a  stricture  of  the  oesophagus,  and  yet 
dysphagia  be  present,  with  an  apparent  obstruc- 
tion to  the  passage  of  food  at  a  point  just  oppo- 
site the  second  intercostal  space,  aneurism  of  the 
arch  may  be  suspected.  A  similar  obstruction 
in  the  oesophagus  at  a  lower  point  might  be  own- 
ing to  enlargement  of  the  descending  aorta,  and 
if  still  lower  and  just  above  the  diaphragm, 
aneurism  of  the  thoracic  aorta  where  this  vessel 
is  crossed  by  the  oesophagus  would  be  probable. 
The  attendant  functional  derangements  vary 
with  the  location  of  the  aneurism.  Thus,  spas- 
modic laryngeal  aflections  would  indicate  pres- 
sure upon  the  recurrent  branch  of  the  pneumo- 
gastric  nerve,  at  a  point  corresponding  with  the 
posterior  and  inferior  portion  of  the  arch  of  the 
aorta,  and  hence  be  suggestive  of  aneurism  at 
this  point,  or  of  the  arteria  innominata.  If  con- 
striction of  the  chest  be  a  prominent  symptom, 
aneurism  of  the  ascending  portion  of  the  arch, 
with  consequent  pressure  upon  the  cardiac  plexus 
would  be  probable  ;  if  orthopnoea  or  asthma,  the 
commencement  of  the  descending  portion,  etc. 

154.  Displacement  of  the  heart,  not  otherwise 
accounted  for — weak  systole — contraction  of  the 
pupils  from  pressure  upon  the  sympathetic  nerve, 
evidence    of    aneurismal   diathesis,   hasmoptysis, 


174  DISEASES   OF   THE  HEART  : 

angina  pectoris,  raucous  voice,  aphonia,  inter- 
costal neuralgia  ;  pain  radiating  from  the  chest, 
or  fixed  at  the  upper  portion  of  the  thorax,  swell- 
ing of  the  feet  or  infiltrated  condition  of  the  eye- 
lids are  signs  which  will  be  construed  by  the  in- 
telligent physician,  as  their  import  in  any  given 
case  may  jastify. 

155.  As  the  tumor  enlarges,  it  may  project 
above  the  sternum,  or  by  its  pressure  produce  ab- 
sorption of  the  osseous  and  cartilaginous  walls  of 
the  chest,  presenting  itself  as  a  soft,  palpable  and 
pulsating  tumor.  The  above  remarks  are  all, 
more  or  less,  applicable  to  aneurism  of  either  the 
pulmonary  arteries  or  of  the  innominata  ;  the 
peculiar  modifications  dependent  upon  the  anato- 
mical relations  of  these  vessels  being  remem- 
bered. Thus,  in  aneurism  of  the  innominata,  the 
tumor  can  be  felt  and  its  boundaries  defined  ;  it 
may  also  produce  dyspnoea  and  dysphagia,  by  its 
pressure  upon  the  nerves  concerned  in  respiration 
and  deglutition.  Its  pressure  upon  the  subcla- 
vian artery  may  obliterate  the  pulse  at  the  right 
wrist  ;  or,  if  upon  the  trachea,  threaten  sufibca- 
tion.  A  full  consideration  of  the  lesions  of  this 
short  but  important  artery  belongs  more  properly 
to  the  province  of  surgery  than  to  that  of  prac- 
tical medicine. 


THEIR    DIAGNOSIS    AND    TREATMENT.  175 

156.  Aneurisms  of  the  pulmonary  or  bronchial 
arteries  are  comparatively  rare,  and  their  diag- 
nosis is,  perhaps,  in  most  cases  impracticable. 
We  should  here,  however,  expect  the  symptoms 
to  be  more  intimately  connected  with  pulmonary 
complications  than  in  similar  affections  of  the 
aorta  or  innominata.  In  such  obscure  cases  the 
practitioner  should  be  guided  by  the  light  of 
anatomy  and  physiology,  without  which  the  most 
simple  problem  in  diagnosis  may  become  an  in- 
comprehensible mystery. 

157.  Auscultation  and  percussion  are  invalu- 
able as  enabling  us  in  many  instances  to  diagnose 
thoracic  aneurisms  before  their  presence  could  be 
communicated  to  the  senses  through  any  other 
channel  ;  they  are  neither,  however,  infallible, 
and  as  is  true  of  all  other  means  at  our  command, 
are  only  susceptible  of  a  limited  practical  appli- 
cation. 

158.  The  ''aneurismal  bruit'^  is  neither  con- 
stant nor  pathognomonic,  but  is  of  value  when 
taken  in  connection  with  other  signs. 

159.  When  this  bruit  is  present,  it  is  not  unlike 
the  sound  produced  by  whispering  the  letters 
h-w-he  e  u-w,  thrown  together  in  the  form  of  a 
word  ;  it  may,  however,  vary  in  pitch  and  inten- 
sity, be  slightly  musical,  rasping  or  blowing,  or 


176  DISEASES   OP   THE    HEART  : 

all  these  variously  combined.  A  "jogging^' 
sound  is  supposed  to  indicate  aortic  dilatation. 
When  these  sounds  are  heard,  they  are,  of  course? 
systolic,  and  must  be  distinguished  from  valvular 
murmurs  by  their  location,  direction  of  propaga- 
tion, etc.  Percussion  may  be  of  value.  It  can 
prove  that  resonance  is  decreased  over  the  region 
of  the  disease  in  these  cases  ;  it  tells-  us  nothing 
more,  however,  except  the  probable  size  of  the 
tumor.  It  does  not  tell  us  whether  the  dullness 
is  caused  by  a  fibrous,  encephaloid  or  aneurismal 
growth. 

160.  Treatment, — The  disease  is  incurable;  and 
if  we  can  prevent,  temporarily  the  fatal  issue,  it 
is  all  that  can  be  expected.  Spontaneous  cure  is 
a  theoretical  possibility,  but  too  remote  to  con- 
stitute a  foundation  for  reasonable  hope.  The 
treatment  should  consist  of  such  management  of 
the  case  as  will  be  most  likely  to  keep  the  circu- 
lation equalized,  and  in  theory  better  still  if  the 
heart's  action  is  constantly  kept  below  its  normal 
force.  The  habits  of  the  patient  should  be  strictly 
regular  and  temperate  in  all  things.  Venereal 
excesses  should  be  especially  forbidden,  and  pas- 
sive rather  than  active  exercise  permitted.  In 
some  advanced  cases,  absolute  rest  must  be  en- 
joined. Tracheotomy  may  temporarily  prolong 
life  where  laryngeal  symptoms  threaten   imme- 


THEIR   DIAGNOSIS   AND   TREATMENT.  177 

diate  suffocation.  The  treatment  of  aneurisms 
of  the  innominata  is  more  properly  a  surgical 
topic.  The  innominata  has  been  ligated  a  num- 
ber of  times,  but  only  once  successfully. 

161.  Cyanosis  is  generally  the  result  of  a  con- 
genital defect  in  the  heart,  such  as  the  non-closure  • 
of  the  foramen  ovale,  and  of  the  ductus-arteri- 
osus.  There  may  be  a  congenital  opening  in  the 
septum  ventriculorum.  It  may  also  depend  on 
arrest  of  growth,  either  before  or  after  birth,  of 
the  root  of  the  pulmonary  artery,  whereby  its 
orifice  is  rendered  permanently  too  small  ;  this 
may  be  the  only  congenital  defect,  the  venous  and 
arterial  blood  not  mixing  at  all.  In  this  case, 
the  blue  tinge  of  the  skin  is  as  easily  accounted 
for  as  in  the  other  malformations. 

RoKiTANSKY  has  seen  cases  of  narrowed  pul- 
monary artery  without  cyanosis.  This  fact  has 
been  often  remarked  by  other  observers.  The 
foramen  ovale  is  frequently  open,  and  yet  there 
is  no  commingling  of  arterial  and  venous  blood, 
unless  the  pulmonary  orifice  is  constricted.  Hence 
it  is  probable  that  obstruction  at  the  ostia  of  the 
heart,  from  constriction  or  other  cause,  combined 
with  patent  foramen  ovale,  open  septum  ventri. 
culorum,  patent  ductus  arteriosis,  or  insufficient 
tricuspid  valves,  is  necessary  to  the  production 

V 


178  DISEASES   OF   THE   HEART  : 

of  cyanosis.  The  venous  stasis,  and  red  and 
purple  blood  mixture,  theories  are  neither  true 
alone,  but  when  both  exist  at  the  same  time, 
cyanosis  must  result.  But  really  the  consid- 
eration of  this  disease  hardly  comes  within  my 
theme— it  belongs  to  works  on  malformations 
of  the  heart,  among  which  that  of  Dr.  Peacock  is 
excellent;  but  I  will  merely  add,  that  we  shall 
find  hypertrophy  of  the  right  ventricle,  etc.,  etc.. 
the  same  catalogue  as  that  which  results  from 
mitral  obstruction  and  patency.  The  treat- 
ment is  not  peculiar,  but  more  difficult,  because 
it  has  to  do  with  children  who  have  not  yet  ar- 
rived at  accountable  age.  Passive  exercise,  slow 
movements,  restricted  and  select  diet,  pure  air, 
special  treatment  on  reflex  principles,  of  the  par- 
oxysms of  dyspnoea  or  syncope  that  frequently 
occur,  are  all  that  can  be  suggested.  The  affec- 
tion is  in  the  end  fatal,  and  this  result  may  be 
postponed,  but  not  averted,  even  by  the  most 
rational  treatment. 

162.  The  lividity  of  atelectasis  of  the  lungs, 
(non-distension  of  air  vesicles,)  sometimes  mani- 
fested in  the  new-born,  cannot  be  mistaken  for 
cyanosis,  resulting  from  malformed  heart.  The 
former  sometimes  disappears  after  a  violent  fit  of 
coughing  ;  the  latter  is  persistent  during  life. 


THEIR   DIAGNOSIS    AND    TREATMENT.  179 


CHAPTER  XI. 

GENERAii  Rules  for  Diagnosis  of  Diseases  of  the 
Heart. 

I.  If  the  patient,  otherwise  in  good  health, 
complain  of  uneasiness  in  the  prsecordial  region, 
cardiac  disease  may  be  expected. 

II.  If  a  murmur  be  heard  at  the  base  systolic 
in  time,  (that  is,  with  the  first  sound  of  the  heart) 
which  diminishes  in  intensity  as  the  ear  is  moved 
towards  the  left  nipple,  it  indicates  roughness  of 
the  semilunar  valves,  or  constriction  or  roughness 
of  the  aortic  orifice. 

III.  If  a  systolic  murmur  be  heard  at  the  prse- 
cordia,  and  if  it  increase  in  intensity  as  the  ear 
is  moved  toward  the  left  nipple,  and  diminish  as 
the  ear  is  moved  up  the  sternum,  it  indicates 
mitral  regurgitation^  that  is,  insufiiciency  of  the 
mitral  valves, 

IV.  A  murmur  heard  at  the  base  of  the  heart 
(about  the  junction  of  the  third  ribs  with  the 
sternum,)  thence  down  the  sternum,  coincident 
with  the  diastole,  (second  sound  of  the  heart,) 
indicates  aortic  regurgitation.     If  to  this  sign  be 


180  DISEASES   OF   THE   HEART; 

added  visible  superficial  pulses,  and  a  liammering 
pulse  at  the  wrist,  aortic  regurgitation  is  certain. 

V.  A  murmur  coincident  with  the  second  sound 
heard  about  the  left  nipple,  or  in  the  fifth  inter- 
space below  and  to  the  right  of  left  nipple,  and 
along  the  heart  towards  its  base,  and  no  where 
else,  indicates  mitral  constriction;  [\his  murmur 
is  very  rarely  heard.]  If  to  this  be  added  a  slight 
cough,  the  lungs  being  .sound,  and  hypertrophy 
of  the  right  ventricle — mitral  constriction  is 
indubitable. 

VI.  A  murmur  heard  loudest  above  the  base 
of  the  heart  in  the  upper  part  of  the  thorax,  indi- 
cates aneurism  of  the  aorta,  or  innominata,  or 
subclavian  artery.  If  to  this  sign  be  added  a 
pulse  of  unequal  strength  in  the  two  wrists,  or 
absent  in  one  wrist,  aneurism  is  almost  cer- 
tain. Difficulty  of  deglutition  and  paroxsyms 
of  dyspnoea  add  greatly  to  the  probabilities  of 
aneurism  ;  indeed,  with  the  preceding  signs,  ren- 
der it  indubitable. 

VII.  If  there  be  bulging  o'f  the  left  side,  near 
'  the  mid.sternum,    and  heaving  impulse    of  the 

heart,  and  strong  full  pulse,  there  is  hypertrophy 
of  the  heart. 

VIII.  If  there  be  a  visible  undulatory  impulse, 
no  heaving  of  chest  if  the  pulse  be  not  strong 


THEIR   DIAGNOSIS   AND   TREATMENT.         181 

nor  very  resistant,  if  the  first  sound  of  the  heart 
be  clear  and  more  distinct,  and  seem  nearer  the 
ear,  and  have  more  of  a  knocking  character, 
than  normal,  there  is  dilatation  of  the  heart.  If 
there  be  much  bulging  of  the  interspaces,  and 
if  the  pulse  be  strong  for  dilatation  and  not 
strong  enough  for  hypertrophy  ;  if  the  apex  be 
outside  of  the  left  nipple  and  below  the  sixth 
rib,  there  is  hypertrophy  with  dilatation.  If 
there  be  also  dropsy  of  the  lower  extremities,  the 
probabilities  of  dilatation  become  certainties. 

IX.  Basic  murmur,  coincident  with  first  sound, 
heard  loudest  at  the  junction  of  the  third  costal 
cartilage  with  the  sternum,  and  thence  down  the 
sternum,  attended  with  persistent  jugular  pulse, 
indicates  almost  positively  tricuspid  regurgi- 
tation— insufficiency  of  the  tricuspid  valves — if 
to  these  two  signs  general  turgidity  of  the  venous 
system  be  added  tricuspid  regurgitation  becomes 
certain. 

X.  An  endocardial  murmur^  whether  systolic  or 
diastolic,  whether  at  the  base  or  apex,  heard 
suddenly  during  the  course  of  an  acute  rheuma- 
tism, or  after  a  violent  blow  on  the  prsecordia, 
or  during  Bright^s  disease  of  the  kidneys,  indi- 
cates endocarditis  in  the  most  positive  manner. 

XI.  An  attrition  or  friction  sound  heard  over 


182  DISEASES   OP   THE   HEART: 

the  prJECordia,  (IT  5,  p.  11.)  that  is,  over  the  fifth 
left  costal  cartilage,  while  the  patient  holds  his 
breath,  indicates  pericarditis,  in  the  most  positive 
manner. 

XXL  Softening  of  the  heart,  without  fatty  de- 
generation, occurs  only  in  cases  of  asthenic  or 
adynamic  diseases  of  an  inflammatory  nature.  If 
in  such  cases  the  pulse  grow  feeble  out  of  ratio, 
with  the  intensity  of  the  adynamic  disease — for 
example,  a  typhus  or  typhoid  fever — and  remain 
weak  and  unequal,  become  easily  excited  and 
fluttering,  if  at  the  same  time  the  patient  feel 
steady  praecordial  uneasiness,  softening,  of  the 
non-fatty  variety,  is  extremely  probable. 

XIII.  If  the  same  symptoms  mentioned  in  the 
foregoing  rule  be  observed  ivi^hon-vivant  of  luxu- 
rious and  idle  habits,  especially  if  he  be  at  the 
same  time  an  intemperate  drinker, /a/^y  degener- 
ation of  the  heart  is  almost  indubitable.  If  to 
these  symptoms  be  added  epileptiform  seizures, 
and  if  the  respiration  varies  greatly  in  uniformity 
as  to  frequency  and  force  without  any  external 
cause,  and  at  the  same  time  the  patient  be  over 
forty  years  old,  fatty  degeneration  may  be  con- 
sidered certain. 

XIV.  Angina  pectoris  cannot  be  mistaken  if 


! 


THEIR   DIAGNOSIS     AND    TREATMENT.         183 

the  suffocation  praecordial  pain,  the  dread  of  im- 
minent death,  have  once  occurred,  so  as  to  be 
described  by  the  patient  in  these  or  similar  terms, 
without  having  been  questioned  by  the  physician. 
The  symptoms  pertain,  in  their  clearness  and 
pertinence,  to  no  other  affection. 

XY.  A  murmur  coincident  with  the  first  sound 
heard  at  the  base  and  propagated  up  the  aorta, 
in  an  anemic  person,  or  in  a  person  whose  blood 
under  the  microscope  exhibits  defect  of  red  or 
excess  of  white  globules,  is  an  inorganic  murmur, 
and  indicates  merely  altered  condition  of  the 
blood,  or  altered  dynamism  of  the  heart. 


General  Principles   of  Treatment  of  Diseases  of 
THE  Heart. 

I.  The  first  and  most  important  principle  to 
be  kept  in  view  in  treating  a  diseased  heart  is 
to  diminish  the  labor  it  has  to  perform. 

II.  This  is  done  in  two  ways,  a.  Directly,  by 
diminishing  the  amount  of  blood  in  the  body;  h. 
By  diminishing  the  functional  activity  of  all  tlie 
organs  not  directly  concerned  in  secretion,  and  by 
increasing  the  functional  activity  of  the  skin, 
liver,  kidneys,  lungs  and  ialimentary  canal. 


184  DISEASES   OF   THE    HEART  : 

HI.  a.  Bbod  may  be  abstracted  directly,  either 
from  the  arm  by  venesection,  or  from  the  prae- 
cordia  by  cups,  when  from  general  plethora  or 
overwhelming  local  congestion,  a  sudden  diver- 
sion to  the  blood  current  is  deemed  essential; 
or  the  total  quantity  of  blood  in  the  system  may 
be  diminished  by  reducing  the  weight  of  the 
body — the  loss  of  eight  pounds  of  weight  is  the 
loss  of  one  pound  of  blood. 

h.  Blood  never  is  to  be  taken  with  a  view  of 
cutting  short  an  inflammation,  or  curing  either 
an  acute  or  clironic  affection,  but  merely  for  ihe 
purpose  of  relieving  an  urgent  symptom,  or  ar- 
resting an  imminent  catastrophe. 

c.  On  the  other  hand,  bleeding  is  not  so  hazard- 
ous as  many  would  wish  us  to  believe,  d.  If  the 
digestive  organs  are  unimpaired,  loss  of  blood 
by  hemorrhage  is  restored  with  astonishing  ra- 
pidity, e.  In  this  respect,  anemia  from  traumatic 
hemorrhage  or  venesection  is  widely  different 
from  pathological  anemia,  depending  on  lesions 
of  nutrition,  assimilation  and  innervation  ;  in 
short,  on  lesions  of  all  the  organs  of  the  body. 
/.  Blood  deterioration  in  this  case  is  repaired 
with  extreme  slowness,  and  this  is  not  to  be  used 
as  an  argument  against  venesection,  leeching,  or 
cupping.     A  few  pints  of  beef  tea  will  restore  as 


THEIR    DIAGNOSIS    AND    TREATMENT.  185 

many  red  globules  as  are  removed  by  a  copious 
bleeding. 

TV,  So  local  bleeding,  even  in  anemia  of  slow 
growth  and  long  duration,  is  not  always  objec- 
tionable to  mitigate  a  threatening  local  symptom. 
a.  For  example  :  take  a  case  in  another  depart- 
ment of  pathology.  A  child  of  six  months,  more 
or  less,  badly  nourished  with  insufficient  mother^s 
milk,  and  cow^s  milk  and  farinaceous  mixtures,  has 
chronic  diarrhoea.  In  the  course  of  treatment 
we  intentionally  diminish  without  arresting  the 
diarrhoea  :  the  child  now  has  tonic  spasm  of  the 
fingers  and  toes,  the  eyes  pitch  back  under  the 
brow,  or  look  straight  onward,  seeing  nothing;  it 
rolls  its  head  and  moans,  and  starts  with  sudden 
shrieks.  This  child  is  anemic,  very  pale,  waxy 
almost,  but  its  head  is  burning  hot.  Now,  if  a 
single  leech  be  applied  at  the  anterior  fontanello 
and  allowed  to  fill,  and  after  it  drops  oflP,  the 
bleeding  be  encouraged  by  the  application  of 
compresses  wrung  out  of  hot  water,  not  only  over 
the  bite,  but  over  the  whole  top  of  the  head,  for 
the  space  of  a  whole  hour;  if  this  be  done  within 
the  first  twelve  hours  after  the  tonic  spasm  be- 
comes manifest,  the  chances  are  more  than  two 
in  three  the  child  will  recover,  providing  it  be 
nourished  with  beef  juicCj  and  medicated  solely 


186  DISEASES   OP    THE  heart: 

with  minute  doses  of  creosote  subsequently,  and 
kept  warm  at  the  abdomen  and  extremities. 
6.  Now,  (his  is  a  case  in  which  an  apology  is 
needed  for  bleeding,  if  an  apology  is  ever  needed; 
yet  I  have  bled  in  twenty  recorded  cases  in  this 
manner,  and  in  seventeen  have  had  the  satisfac- 
tion of  seeing  my  little  patients  recover. 

V.  As  a  general  rule,  depletion  by  bleeding  is 
not  required  in  diseases  of  the  heart. 

YI.  By  abstinence  from  hard  labor,  mental  or 
physical;  by  abstinence  from  all  severe  exercise, 
and  by  avoiding  all  violent  emotions  or  passions, 
the  demands  of  the  heart  are  obviously  lessened, 
and  hence  its  labor  lightened. 

YII.  By  aperients  regularly  taken,  by  diure- 
tics often  repeated,  by  hepatic  stimulants  taken 
from  time  to  time,  by  unobstructed  access  to  the 
atmosphere  at  all  hours  of  the  day  and  night,  by 
baths,  frictions  and  abundant  passive  exercise, 
the  functions  of  the  liver,  skin,  lungs,  kidneys  and 
alimentary  canal  are  certainly  increased,  and 
that  not  in  a  way  to  be  detrimental  to  alimenta- 
tion, assimilation  and  nutrition. 

VIII.  Whatever  degree  of  sedative  impression 
we  desire  to  make  on  the  heart,  must  be  made 
slowly,  not  suddenly.  A  violent  blow  on  the  pit 
of  the  stomach  will  stop  the  heart  forever.     A 


THEIR   DIAGNOSIS   AND   TREATMENT.  187 

thousand  light  blows  or  a  heavy  weight  would 
produce  but  little  effect.  Small  doses  of  cardiac 
sedatives,  often  repeated  and  carefully  watched, 
are  better  than  large  ones,  however  judiciously 
administered. 

IX.  The  quality  of  the  blood  must  he  main' 
tained  as  near  the  normal  standard  as  'possible^  while 
its  quantity  may  he  diminished  by  restricted  diet, 
and  certain  evacuants^  in  proportion  as  the  disease  of 
the  heart  advances. 


CHAPTER  XIL 

General  Reflections   as  to    Prognosis   in    Organic 
Diseases  of  the  Heart. 

163.  Heart  disease  destroys  life  in  three  ways: 
a,  by  syncope  ;  5,  by  apncea  ;  c,  by  so  interfering 
with  assimilation  as  to  cause  gradual  destruction 
of  life  from  inanition — starvation,  not  from  defec- 
tive food  or  defective  appetite,  but  from  defective 
assimilation  and  aeration  of  the  blood. 

By  far  the  most  common  special  organic  disease 
of  the  heart  is  that  of  the  mitral  valves.  Insuffi- 
ciency of  the  mitral  valve  is  exceedingly  common 
in  this  city  :  cases  may  be  counted  by  hundreds. 
Now,  what  is  the  result  ?     Insufficiency  of  this 


188  DISEASES    OF   THE    HEART  : 

valve  is  not  incompatible  with  the  longest  life. 
If  the  insufficiency  be  slight,  but  little  blood  is 
repelled  at  the  ventricular  systole  into  the  left 
auricle,  and  this  becomes  slightly  or  not  at  all 
hypertrophied  ;  the  left  ventricle  in  such  case 
may  remain  unhypertrophied.  But  the  usual 
course  is,  the  left  auricle  thickens;  the  pulmonary 
vessels  become  congested,  more  or  less,  with  the 
refluent  blood;  this  reacts  on  the  right  ventricle, 
which  becomes  hypertrophied.  Here  the  case 
may  remain  stationary  for  years,  or  for  life;  and 
rational  treatment  may  greatly  help  to  insure 
this  result  ;  but  usually,  from  neglect  or  other- 
wise, the  disease  advances.  The  thin-walled 
right  ventricle,  being  only  designed  for  impelling 
the  venous  blood  through  the  pulmonary  arteries 
and  capillaries  around  to  the  left  side  of  the 
heart,  laboring  under  the  great  burden  of  re- 
jecting the  increased  volume  of  blood  thrown 
back  up*on  it  from  the  powerful  left  ventricle,  now 
itself  reinforced  by  hypertrophy,  and  aided  in  its 
damaging  ability  by  the  dilated  pulmonary  ves- 
sels, begins  to  dilate.  Now  nature  steps  in  again, 
to  counteract  one  disease  by  another.  The  tri- 
cuspid valves  become  incompetent,  from  the  dila- 
tation of  the  right  ventricle,  and  part  of  the 
venous  blood  is  repelled  by  the  systole  of  the 
right  ventricle  upon  the  vena  cavce,  and  again 


THEIR    DIAGNOSIS   AND   TREATMENT.  189 

there  is  rest.  Even  now,  by  judicious  treatment, 
by  reducing  the  weight  of  the  body,  and  hence 
the  volume  of  blood,  while  assimilation  is  not 
allowed  to  become  impaired,  life  may  continue 
for  many  years,  and  the  patient  die  perhaps  of 
old  age.  But  generally  no  steady  persistent 
treatment  is  permitted  by  the  patient.  He  goes 
from  one  good  physician  to  another,  and  obeys 
none  long  enough  to  receive  permanent  benefit, 
and  in  the  nature  of  the  case  he  is  unable 
to  treat  himself  judiciously  ;  hence  the  disease 
enters  on  its  third  and  last  stage.  The  heart  in 
its  enfeebled  condition  being  overworked,  by 
having  to  impel  too  much  blood  relative  to  its 
ability,  makes  new  efi'orts  at  reparation  in  detail, 
only  to  hasten  the  ultimate  result :  that  of  ren- 
dering the  heart  totally  incapable  of  performing 
its  functions  ;  thus,  the  left  ventricle  becomes 
more  hypertrophied,  and  if  the  left  auricle  has 
not  yielded  to  dilatation  in  excess  of  hypertrophy, 
the  left  ventricle  may  also  become  slightly  di- 
lated at  first ;  but  this  dilatation  never  advances 
far,  for  the  left  auricle  soon  yields,  and  becomes 
so  dilated  as  no  longer  to  be  able  to  afiect  the 
ventricle  by  its  contractions.  By  this  time  the 
dilatation  of  the  right  ventricle  has  become  enor- 
mous, and  in  excess  of  its  hypertrophy.  The  tri- 
cuspid is  now  constantly  insufiicient  ;  the  jugular 


190  DISEASES   OP   THE   HEART  : 

pulse  is  always  visible,  night  and  day  ;  the  lungs 
are  congested  ;  the  breath  gives  out  on  the  least 
hurry.  There  is  oedema  of  the  lower  extremities, 
dyspepsia,  congested  liver,  still  more  oppressed 
respiration,  greater  lack  of  aeration  of  blood  in 
the  pulmonic>esicles;  face  looks  purple,  or  deep 
red,  perhaps  maroon-colored.  The  patient  is  very 
much  disposed  to  be  cold,  seldom  perspires;  there 
is  occasional  spitting  of  blood;  the  pulse  becomes 
weaker  and  less  uniform,  even  in  its  weakness. 
The  end  of  such  a  case  is  obvious;  but  often  such 
a  progress  and  result  might  be  almost  indefinitely 
postponed.  Insufficiency  of  the  mitral  valve, 
while  it  is  the  most  comnjon,  is  fortunately  the 
least  fatal  in  its  tendency  of  all  the  organic  dis- 
eases of  the  heart,  and  the  most  controllable  by 
systematic  treatment. 

164.  Mitral  constriction,  if  slight,  is  not  in- 
compatible with  tolerable  health  and  long  life; 
but  when  the  constriction  is  considerable,  its  con- 
sequences follow  in  more  rapid  succession.  Here 
the  left  heart  remains  unaffected,  or  may  become 
atrophied  for  lack  of  work  ;  for  obviously,  if  the 
constriction  is  so  great  as  to  admit  but  half  the 
blood  current  in  a  given  time,  the  left  heart  has 
but  half  work  to  perform.  A  moderate  constric- 
tion nature  compensates,  by  the  hypertrophy  of 


THEIR   DIAGNOSIS    AND    TREATMENT.  191 

the  right  ventricle,  and  probably  of  the  pulmonary 
arterial  walls  also.  The  right  ventricle  also  be- 
comes hypertrophied  all  the  more  when  the  con- 
striction is  considerable,  and  this  is,  of  course, 
curative  in  its  tendency;  and  if  the  hypertrophy 
of  the  right  ventricle  balance  the  constriction 
of  the  mitral  orifice,  so  that  by  its  action  the 
same  amount  of  blood  is  forced  through  in  a  given 
time,  as  though  it  were  not  constricted,  then  the 
hj-pertrophy  is  absolutely  compensatory,  and  prac- 
tically the  patient  is  cured.  This  no  doubt  does 
sometimes  happen  and  continue  through  a  long 
life.     But  generally  it  is  far  otherwise. 

165.  The  blood  not  being  able  to  flow  into  the 
left  ventricle  in  normal  volume,  accumulates  in 
the  left  auricle,  which  hypertrophies  by  increased 
function  ;  but  still  being  unable  to  impel  the 
blood  onward  as  fast  as  it  arrives,  part  of  its 
contractile  force  is  expended  backwards  upon  the 
pulmonary  veins,  which  becoming  congested,  im- 
pede the  onward  current  from  the  pulmonary  arte- 
ries, and  so  back  to  the  right  heart,  as  in  mitral 
insufficiency.  Insufficiency  being  almost  always 
joined  with  constriction,  we  get  the  same  train 
of  symptoms  exaggerated,  to  which  may  be  added 
tendency  to  syncope,  and  sometimes,  though 
rarely,  death  from  this  calise  ;  because  enoufrh 


192  DISEASES    OF    THE    HEART  : 

blood  may  not  reach  the  arteries,  in  consequence 
of  the  constriction,  to  supply  the  brain  ;  but 
almost  always  death  occurs  by  apncea,  as  previ- 
ously stated. 

166.  Disease  of  aortic  valves,  whether  insuffi- 
ciency or  constriction,  produces  an  opposite  train 
of  symptoms,  and  is  more  speedily  lethal  in 
its  tendency;  and,  indeed,  is  less  controllable  by 
treatment,  whether  hygienic  or  remedial. 

167.  Aortic  obstruction,  indicated  by  a  sys- 
tolic murmur,  loudest  at  the  base,  that  is,  about 
the  middle  of  the  sternum,  opposite  to  the  third 
intercostal  spaces,  and  aortic  insufficiency,  indi- 
cated by  a  diastolic  murmur,  heard  loudest  at  the 
same  place,  and  propagated  down  the  sternum, 
are  more  commonly  met  with  jn  middle  or  ad- 
vanced age  than  in  earlier  life,  and  more  fre- 
quently in  males  than  females;  while  females  are 
more  liable  to  mitral  disease  than  to  any  other 
affection  of  the  heart. 

168.  These  two  affections  of  the  aortic  valves, 
when  of  long  standing,  are  generally  attended 
with  enormous  eccentric  hypertrophy  of  the  left 
ventricle,  and  final  incompetency  of  the  mitral 
valve,  congestion  of  the  pulmonary  vessels,  and 
finally,  if  the  patient  live  long  enough,  hypertro- 


THEIR   DIAGNOSIS     AND    TREATMENT.         193 

phy  and  dilatation  of  the  right  heart,  tricuspid 
regurgitation,  engorged  systemic  veins,  impaired 
blood,  serous  infiltrations,  dyspnoea,  cough,  syn- 
cope and  death.  The  order  mentioned  is  the 
usual  one  in  which  nature  attempts  restoration  at 
every  step  of  the  advancing  disease. 

169.  Hypertrophy  of  the  left  ventricle  is  com- 
pensatory of  obstruction  or  regurgitation  at  the 
aortic  valves,  or  of  both;  dilatation  is  a  new 
step  in  the  fatal  direction,  and  then  mitral  regur- 
gitation comes  in  as.  compensatory  to  that.  Left 
auricular  hypertrophy  and  dilatation  tends  to 
prevent  the  excessive  injury  to  the  pulmonary 
vessels,  by  recoil  from  the  ventricle,  and  then, 
when  this  resource  fails,  the  pulmonic  valves  in- 
crease in  strength,  and  the  right  ventricle  takes 
on  hypertrophy,  as  a  new  compensation  for  the 
ever  widening  mitral  orifice. 

170.  Then  another  step  in  disease  is  dilatation 
,  of  the  right  ventricle,  followed  by  a  compensa- 
tory lesion,  namely  incompetency  of  the  tricuspid 
valves,  with  its  attendant  regurgitation  ;  then 
disease,  in  the  giving  way  of  the  valves  of  the 
veins,  before  the  refluent  venous  current  and  the 
attendant  venous  congestions;  then  a  final  and 
last  effort  at  compensation  in  serous  exosmosis  or 
dropsy. 

X 


194  DISEASES   OF   THE   HEART: 

171.  Thus  it  is  seen  that  each  advance  of  the 
disease  is  met  bj  a  compensatory  lesion,  which, 
while  it  adds  to  the  sum  total  of  organic  damage, 
retards  the  fatal  progress  of  each  integral  lesion, 
reinforced,  as  it  is,  with  all  its  antecedents. 

172.  At  each  of  these  compensatory  struggles, 
art  is  able  to  give  nature  valuable  aid  in  the 
prolongation  of  life,  and  in  averting  sudden  acci- 
dents. 

173.  A  small  aortic  obstruction  or  a  trifling 
insufficiency  of  the  semilunar  valves,  may  be  so 
accurately  compensated  for  by  hypertrophy  as  to 
produce  inappreciable  results,  and  not  noti(;^bly 
shorten  life.  A  considerable  insufficiency,  with- 
out obstruction,  may  be  so  compensated  by  hyper- 
trophy as  to  produce  no  evil  consequences,  so 
long  as  the  mitral  valves  remain  competent ;  and 
this  latter  result  may  be  indefinitely  postponed 
by  such  treatment  as  has  been  suggested  in  former 
chapters.  . 

174.  The  narrowing  of  the  aortic  orifice  to 
one-fifth  its  normal  condition,  is  not  incompatible 
with  the  continuation  of  life  and  the  enjoyment 
of  unsuspected  health,  providing  it  be  recognized, 
and  the  patient  placed  under  rational  treatment 
and  constant  care;  for  it  is  quite  probable  the 
left    ventricle    may    become    so     strengthened 


THEIR   DIAGNOSIS   AND    TREATMENT.  195 

by  hypertrophy  and  innervation,  as  to  be  able  to 
propel  the  blood  with  a  velocity  sufficiently  in- 
creased to  compensate  for  the  defective  aperture 
through  which  it  has  to  pass. 

175.  Still  it  is  not  denied  that  aortic  valvular 
diseases  are  generally  fatal  at  no  long  period 
after  their  recognition,  much  more  promptly  than 
other  valvular  lesions.  A  little  hurry,  a  violent 
passion,  a  sudden  motion,  is  liable  to  surprise  the 
heart  and  cause  its  arrest  for  an  instant,  during 
which  syncope  takes  place,  from  lack  of  supply 
of  arterial  blood  to  the  ganglia,  and  this  syncope 
is  too  often  final. 

176.  Tricuspid  regurgitation  is  a  fatal  affection 
and  only  less  dangerous  as  to  the  imminence  of  its 
result  than  aortic  valvular  disease.  A  fatal  ter- 
mination may  be  a  long  time  postponed,  by  dimin- 
ishing the  volume  of  blood  in  the  system,  by  means 
of  restricted  diet,  diuretics,  evacuants,  etc.,  ac- 
cording to  the  general  principle  often  suggested 
in  the  course  of  this  volume  ;  that  is,  by  reducing 
the  iveigkt  of  the  body  without  impairing  the  quality 
of  the  blood.  But  the  progress  of  tricuspid  lesions 
cannot  be  retarded  to  the  same  degree  as  those 
of  the  mitral  or  even  semilunar  valves.  And, 
while  it  is  well  known  that  occasional  dynamic 
incompetency  of  the  tricuspid,  or  slight  organic 


196  DISEASES   OF   THE   HEART  : 

incompetency  is  not  incompatible  with  unsus- 
pected health,  yet  it  is  no  less  true  that  consider- 
able incompetency  of  this  valve  is  incompatible 
with  assimilation,  and  with  oxygenation  of  the 
blood,  and  hence  must  prove  fatal  within  a  com- 
paratively short  period  from  the  moment  when  it 
becomes  well  established. 

177.  Fatty  degeneration^  admits  of  postpone- 
ment within  narrow  limits,  as  to  its  result ;  but 
the  fatal  end  will  arrive  when  least  expected, 
and  often  much  sooner  than  the  symptoms  would 
seem  to  render  probable. 

Acute  pericarditis  is  seldom  fatal.  Acute  eiido- 
carditis  is  somewhat  more  frequently  fatal,  but 
not  more  so  than  pneumonia.  It  almost  always 
leaves  disease  of  tlje  valves,  which  in  the  end 
but  perhaps  not  for  half  a  century,  produce  death 
by  annulling  the  function  of  the  heart. 

178.  Fibrinous-clots  in  the  heart  almost  always 
cause  death  in  from  three  hours  to  as  many  days. 

179.  Ruptures  of  the  heart,  de  natura  suarum 
are  rapidly,  though  not  instantly  fatal.  Cardiac 
dropsies  are  curable  by  means  already  indicated. 

180.  Hypertrophy y  or  hypertrophy  with  dilatation^ 
pure  and  simple,  are  possibly  curable  ;  but  such 
a  result  is  as  improbable  as  that  both  or  either 
of  these  lesions  can  exist  without  organic  disease 


THEIR  DIAGNOSIS  AND   TREATMENT.  197 

of  the  valves,  of  the  lungs,  or  of  the  arteries  ;  or 
at  least  without  the  presence  of  some  external 
obstruction  to  the  circulation  of  great  and 
persistent  inertia. 

Finally  :  it  may  be  affirmed  that  after  the  first 
chronic  lesion  of  the  heart,  the  others  come  on — 
first,  compensatory;  second*  deteriorative;  third, 
compensatory  ;  fourth^  more  deteriorative  ;  fifth, 
compensatory  ;  and  so  on,  until  its  function  is 
annihilated. 

Corrollary,  The  whole  object  of  treatment  is 
to  aid  nature  in  these  purposes,  by  diminishing 
the  work  the  heart  has  to  do,  in  proportion  as  its 
functional  ability  diminishes,  that  is,  in  propor- 
tion as  its  organic  lesions  advance. 


198  DISEASES   OF   THE   HEART  : 

Matter  Inadvertently  Omitted  in  Chapter  V. 

Incompetency  and  constriction  of  right  auriculo- 
ventricular  orifice, — Incompetency  of  the  tricuspid 
valves  is  recognized  by  tolerably  certain  signs, 
not  difficult  of  recognition  or  appreciation.  Thus, 
if  there  be  persistent  jugular  pulse  in  all  posi- 
tions of  the  body,  especially  the  upright,  tricus- 
pid incompetency  is  almost  certain.  There  may 
or  may  not  be  a  blowing  murmur  heard  over  the 
tricuspid,  (that  is,  over  the  sternum  between  the 
ends  of  the  fourth  interspaces  at  the  right  margin 
of  the  breast-bone,)  such  a  murmur  would  be 
propagated  up  and  down  the  sternum,  in  the 
direction  of  both  the  venae  cavae;  but  on  account 
of  the  feeble  condition  in  which  the  right  ven- 
tricle usually  is,  from  dilatation,  at  the  period  of 
tricuspid  incompetency,  the  murmur  would  be 
inaudible  a  short  distance  from  its  origin;  it  is, 
perhaps,  never  heard  at  the  apex.  The  murmur 
is  much  less  frequent  than  the  disease  it  indi- 
cates, because,  as  already  remarked,  it  is  not 
always  audible  ;  and,  moreover,  it  is  often 
marked  by  a  loud  regurgitant  murmur,  as  mitral 
incompetency  generally  precedes  and  co-exists 
with  tricuspid  incompetency.  Tf  the  incompe- 
tency is  considerable,  there  is  generally  oedema 
of  the  lower  extremities,  though  dropsy  is  not  a 


THEIR   DIAGNOSIS   AND   TREATMENT.  199 

necessary  result  of  any  degree  of  valvular  disease. 
This  affection  is  likely  to  induce  headache  from 
cerebral  congestion,  and  perhaps  true  softening 
of  the  brain,  from  habitual  venous  congestion. 
The  treatment  is  that  of  dilatation^  and  other  val- 
vular diseases. 

Tricuspid  constriction  will  rarely,  if  ever,  fur- 
nish an  audible  murmur.  If  heard  at  all,  it 
should  be  loudest  at  the  ensiform  cartilage,  or 
over  the  cartilage  of  the  fourth  right  rib  ;  if 
associated  with  tricuspid  incompetency,  there 
might  be  a  double  murmur.  In  the  present  state 
of  knowledge,  the  positive  diagnosis  of  tricuspid 
constriction  is  simply  impossible.  This  is  not 
much  to  be  regretted,  for  it  must  be  miraculously 
rare,  and  if  present,  it  has  no  fatal  or  dangerous 
significance,  unless  it  be  very  considerable. 


ERRATA. 


There  are  several  typographical  mistakes,  and  some  errors 
in  syntax  in  different  forms,  the  proofs  of  which  I  did  not 
have  an  opportunity  to  revise,  but  as  they  do  not  affect  the 
meaning  of  the  text,  they  are  not  referred  to  in  the  errata. 

Omit  "  backwards,"  first  line,  page  22 ;  page  102,  for 
"growth"  read  growths  ;  page  160,  for  "shreds  of  a  fleshy 
column"  read  shreds  of  the  fleshy  colunms  ;  page  95,  for 
"  hypertrophous  dilatation"  read  hypertrophy  with  dilata- 
tion. 


APPENDIX. 


A. 

T  8,  page  12.  "  The  first  sound  of  the  heart  is  caused  by 
the  closure  of  the  auriculo-ventricular  valves,  mitral  and  tri- 
cuspid," etc.  In  asserting  this,  I  mean  that  the  closure  of 
the  auriculo-ventricular  valves  is  the  chief  cause  of  the  first 
sound,  and  a  cause  which  is  no  longer  debatable,  since  it  has 
been  repeatedly  demonstrated  as  the  most  efficient,  and  at 
least  the  climax  of  all  the  causes  of  the  first  sound.  But 
every  well-practiced  ear  will  appreciate  the  beginning  of  a 
sound  in  the  systole  of  the  heart,  of  which  the  sudden  tension 
of  the  auriculo-ventricular  valves  is  the  complement ;  thus, 
in  incompetent  mitral  valves,  we  appreciate  a  dull,  muffled, 
indefinite  systolic  sound,  terminated  by  the  murmur  of  regur- 
gitation, instead  of  by  the  click  of  closure  of  a  perfect  mitral 
valve.  This  dull,  prolonged,  muffled,  undulatory  sound,  is, 
to  my  mind,  undoubtedly  the  muscular  element  of  the  first 
sound,  reinforced  by  the  pressing  stroke  of  the  heart  against 
the  thorax,  and  perhaps  also  by  the  rush  of  blood  through 
the  aorta  and  pulmonary  artery.  I  am  sure  the  mechanism 
and  time  of  the  first  sound  is  appreciable,  by  the  duration  and 
force  of  an  indeterminable  muffled  sound,  even  when  both  the 
tricuspid  and  mitral  valves  are  incompetent. 

B. 

a,  page  33.  "  But  there  is  reason  to  believe  its  origin — 
[arrest  of  the  systolic  movement  of  the  heart]  lies  rather  in 
lesion  of  some  portion  of  the  cerebro-spinal  axis,  than  in«,ny 

a 


303  APPEl^DIX. 

alteration  in  tlie  structure  of  tlie  heart  itself."  I  grant  tins 
suggestion  admits  of  no  positive  proof  in  the  present  state  of 
knowledge.  The  lucid  experiments  of  Claude-Bernard  have 
shown  that  irritation  of  the  pneumogastric  nerve  slows  or 
arrests  the  heart's  contractions.  Now,  this  is  accomplished 
whether  the  irritation  be  applied  directly  to  the  pneumogas- 
tric nerve,  between  the  heart  and  brain,  or  to  the  roots  of  the 
pneumogastric  in  the  lateral  tract ;  or  to  a  branch  of  the 
pneumogastric  ramifying  on  the  heart  itself ;  or,  in  short,  to 
any  sensitive  filament  in  any  part  of  the  body  not  of  the 
pneumogastric.  If  the  irritation  affects  a  sensitive  nerve,  it 
is  instantly  reflected  through  the  sympathetic  upon  the 
heart  ;  and  if  the  sensation  be  sufficiently  violent  or  painful, 
the  heart  is  arrested  either  temporarily  or  forever;  if  mo- 
mentarily, the  pulse  intermits ;  if  temporarily,  the  pulse 
stops  several  beats  ;  if  the  arrest  is  only  partial,  the  pulse 
hesitates,  but  goes  on.  Now,  all  these  phenomena  are  ob- 
served in  the  variations  of  the  pulse  in  the  different  lesions 
of  the  heart.  Hence  I  am  compelled  to  modify  the  suggestion 
in  the  text,  quoted  at  the  head  of  this  note,  and  substitute 
something  like  the  following  formula :  There  is  reason  to 
believe  the  origin  of  arrest  of  the  systolic  movement  of  the 
heart  lies  sometimes,  in  lesions,  of  the  cerebro-spinal-axis — 
for  example,  lack  of  supply  of  arterial  blood  to  the  portion  of 
the  encephalon,  in  which  the  vagus  originates ;  [in  conse- 
quence of  an  atheromatous  or  ossified  artery,  etc.,  etc.,]  or 
some  defect  in  the  cerebrum,  by  which  the  motor  function 
fails  to  respond  promptly  to  sensation,  or  irritation,  etc.  But 
it  is  altogether  probable  that  the  cause  of  arrest  of  systolic 
movement,  whether  temporary  or  perpetual,  may  and  does 
often  exist  in  the  very  substance  of  the  heart  itself,  or  in  the 
quality  or  quantity  of  the  blood  circulating  through  it,  or  in 
the  occasional  irritation  produced  by  some  analogous  or 
heterologous  growth  in  or  about  the  heart.  So  whether  the 
influence,  irritation,  sensation  or  impression,  come  from  the 


APPENDIX.  203 

surface  of  the  body  through  the  sensitive  filiments,  through 
the  cerebrospinal  axis,  or  from  the  internal  organs  or  tis- 
sues  through  the  sympathetic,  or  from  the  cerebrum  enceph- 
alon  itself,  in  consequence  of  an  intellection,  an  emotion, 
or  physical  impediment,  it  is  liable  to  cause  arrest  of  the 
systolic  movement,  or  complete  suspension  of  the  heart's 
action  for  a  moment  or  forever,  according  to  the  nature  and 
force  of  the  influence,  etc. 


Causes  op  Dropsy. — Dropsy  is  caused  by  something  more 
than  mere  venous  or  capillary  obstruction.  The  blood  must 
become  deteriorated  in  albumen  before  true  dropsy  can  take 
place.  Dropsy  is  a  demonstrative  evidence  of  anemia.  There 
can  be  no  dropsy  without  anemia,  but  there  may  be  excessive 
anemia  without  dropsy,  because  the  transudation  of  serum 
does  not  take  place,  even  in  true  hydremia  of  the  blood,  un- 
less there  is  also  obstruction  to  the  circulation.  Dropsy  does 
not  take  place  until  the  protein  principles  (which  in  the 
blood  are  79  in  1,000,)  are  reduced  to  63  or  58  in  1,000.  It 
will  be  understood  that  dropsy  is  not  an  exudation  of  inflam- 
mation ;  the  dropsical  liquid  contains  no  coagulable  fibrin,  an " 
exudation  does.  The  cause  of  dropsy  in  Bright's  disease  is 
the  diminution  of  albumen  in  the  blood  by  the  albumenuria, 
in  consequence  of  which  the  serum  charged  with  still  more 
albumen,  is  apt  to  transude,  and  thus  the  blood  is  still  fur- 
ther impoverished,  not  merely  by  the  abstraction  of  albumen 
and  fibrin  in  solution,  but  by  the  endosmosis  chloride  of 
sodium  [eight  jDarts  of  chloride  of  sodium  replace  one  of  albu- 
men] and  water  for  its  solution.  The  diminution  of  albumen 
and  increase  of  salts  andtcater  are  rigorously  coincident  facte. 
This  diminution  of  albumen  in  the  blood,  then,  is  the  true 
cause  of  its  capability  of  transudation  ;  and  now,  if  we  have 
any  obstruction  to  the  circulation,  we  have  dropsy. 

From  what  is  here  suggested,  it  is  easily  understood  why 


204  APPENDIX. 

extreme  constriction  of  tlie  tricuspid  orifice  may  be  present 
and  dropsy  be  absent.  Here  we  may  have  only  one  condition 
of  dropsy — obstruction  to  the  venous  circulation — wliile  the 
blood  may  contain  its  normal  ratio  of  albumen,  and  so  be  in- 
capable of  transudation  :  but  once  impair  this  ratio  from 
75  to  60  in  1,000,  and  we.have  dropsy.  The  integrity  of  the 
blood  is  maintained  by  respiration  and  alimentation ;  ob- 
struct either  and  we  induce  a  condition  favorable  to  dropsy  ; 
hence  the  necessity  of  just  alimentation,  and  the  freest  res- 
piration in  chronic  diseases  of  the  heart,  since  these  are 
always  obstructive  to  the  circulation. 

The  true  indication  of  treatment  for  the  cure  of  dropsy 
is  obvious — restoration  of  the  blood  to  its  normal  condition 
as  to  albumen,  and  removal  of  the  obstruction  to  the  circula- 
tion. The  latter  in  case  of  heart  disease  is  impossible  in  a 
direct  but  not  in  a  relative  sense.  Thus,  the  weight  of  the 
body  may  be  reduced,  and  so  the  blood  1  to  8 ;  and  in  some 
cases  it  is  practicable  to  so  reduce  the  quantity  of  blood, 
without  impairing  its  quality,  that  the  obstruction  may  be- 
come null.  If  the  blood  be  restored  to  its  normal  quality  at 
the  same  time,  the  transudation  will  be  arrested,  and  the 
existing  dropsy  will  disappear  by  the  natural  secretory  func- 
tions, stimulated  to  unusual  activity  for  a  few  days. 

D. 

On  page  42,  I  said  I  would  attempt,  in  a  subsequent  para- 
graph, to  explain  the  mode  of  death  in  disease  of  the  mitral 
valve. 

It  is  now  well  understood  that  the  cause  of  death  in  lesions 
of  the  aortic  valves  is  the  lack  of  supply  of  arterial  blood  to 
the  ganglia,  both  cerebro-spinal  and  sympathetic,  and  that 
the  mode  of  death  is  by  syncope.  The  immediate  cause  of 
death  in  aortic  lesion  is  very  well  stated  by  M  Mauriac, 
page  82. 


APPENDIX.  205 

The  cause  of  death  in  mitral  lesions  is  altogether  different. 
Death  is  here  caused  by  habitual  congestions  of  all  the  organs 
behind  the  mitral  valve,  the  lungs,  liver,  kidneys,  etc.  Death, 
when  it  occurs  immediately,  in  mitral  disease,  is  always  by 
apncea,  and 'never  by  syncope.  The  breathing  becomes  diffi- 
cult, long  before  death;  the  engorged  capillaries  transude 
their  excess  into  the  cellular  tissue,  and  cause  those  oedema- 
tous  infiltrations  of  the  lower  extremities  so  frequent  in 
mitral  regurgitation.  There  are  attacks  of  acute  congestion 
and  even  of  inflammation  of  the  kidneys,  attended  by  albu- 
menuria,  by  which  the  blood  is  stil  more  permanently  deteri- 
orated. As  the  disease  advances,  albumenuria  becomes  more 
frequent  and  less  curable.  Now  there  is  progressive  loss  of 
flesh,  recurring  serous  infiltrations  (which  are  removable  by 
purgatives,  dry  diet,  diuretics,  expectorants,  etc. ;)  but  the 
struggle  of  art  with  an  incurable  disease  cannot  last  always, 
and  if  the  patient  does  not  die  in  a  sudden  paroxysm  of 
apnma,  from  pulmonary  congestion  and  bronchial  engorge- 
ment, he  eventually  succumbs  to  the  exhausting  nature  of  the 
disease,  and  dies  from  defective  alimentation  and  aeration  of 
the  blood  combined. 

For  the  views  expressed  on  page  67,  et  passim,  concerning 
the  cause  of  pain,  I  am  indebted  to  "  Radclifie  on  Pain,"  etc. 

"  E. 

d.  page  108.  I  do  not  wish  to  be  imderstood  that  any 
considerable  eff'usion  into  the  pericardium  would  not  cause 
prsecordial  bulging,  but  simply  that  an  efl"usion  may  be  so 
slight  as  to  cause  no  appreciable  alteration  in  the  contour  of 
the  thoracic  walls.  I  have  also  omitted  a  sign  which  is  very 
distinctive  of  the  effusion  stage  of  pericarditis,  when  the  effu- 
sion is  considerable  ;  that  is,  the  marked  increase  of  trian- 
gular dullness  in  the  direction  of  the  apex  of  the  rude  tri- 
angle represented  by  the  heart  and  roots  of  the  great  vessels. 


206  APPEI^DIX. 

The  apex  of  this  dullness  has  been  known  to  rise  as  high  as 
the  left  clavacle,  and  the  whole  triangular  dullness  to  occupy 
the  whole  front  and  lateral  portion  of  the  thorax,  w^liile  the 
base  of  the  triangular  dullness  did  not  fall  below  its  usual 
place,  the  lower  margin  of  the  sixth  rib. 

F. 

Page  110.  "  The  absent  first  sound  was  as  accountable  on 
the  supposition  of  effusion,  as  of  softened  heart."  This  has 
has  been  objected  to,  because  it  is  said  water  is  a  good  con- 
ductor, and  should  transmit  the  first  sound  if  it  were  present 
In  answer,  I  have  only  to  say,  that  in  this  case  more  than 
half  of  the  first  sound  was  absent  by  defect  of  mitral  valves  ; 
and  it  is  certain  that  the  remaining  portion  could  not  be 
heard  as  well  through  eight  ounces  of  effusion  as  if  the  effu- 
sion were  not  present ;  moreover,  the  absence  of  the  first 
sound  in  fatty  degeneration  in  the  last  stage  is  unaccountable 
if  the  two  sets  of  auriculo-ventricular  valves  are  competent ; 
that  is,  the  absence  of  that  portion  of  the  first  sound  caused 
by  the  click  of  the  auriculo-ventricular  valves ;  for  although 
from  the  degeneration  of  the  fleshy  columns,  on  the  contrac- 
tion of  which  depend  the  click  of  the  valves,  the  sound  should 
be  diminished,  yet  if  they  shut  with  suflScient  force  and 
promptness  to  resist  the  resilience  of  a  sound  aorta,  they 
should  emit  a  sound  as  audible  at  the  praecordia,  as  that  pro- 
ceeding from  the  same  valves  when  the  heart  is  oppressed 
with  a  distended  pericardium,  and  its  own  dynamism  thereby 
materially  diminished,  as  also  by  the  impediment  to  the 
circulation  of  the  blood  in  its  own  substance,  which  must 
further  materially  diminish  the  vigor  of  the  systoles.  Hence, 
the  proposition  quoted  seems  to  me  not  inexact. 

G. 

Page  111.  "  Saline  evacuants,"  are  to  be  used  only  when 
emaciation  is  still  slight,  or  when  with  much  loss  of  adipose 


APPENDIX.  307 

and  atrophy  of  muscular  tissue,  there  is  considerable  dropsy. 
In  this  latter  condition  only  temporary  benefit  can  be  hoped 
for,  and  the  salines  cannot  be  used  with  the  same  energy  and 
persistence  as  in  the  less  asthenic  dropsies.  As  a  general 
rule,  whenever  there  is  defective  alimentation,  and  hence 
impaired  hematosis,  the  "  warm"  aperients  or  carthartics  are 
preferred  to  the  salines  :  aloetic,  or  compound  colocynth,  pills, 
or  pills  of  rhubarb,  aloes  and  senna,  to  which  some  carmina- 
tive may  be  added,  are  perhaps  the  best,  both  in  theory  and 
practice.  But  if  the  dynamic  condition  of  the  patient  is  such 
as  to  tolerate  it,  (and  that  of  the  case  mentioned  was  such 
an  one,)  the  saline  treatment  is  much  the  best.  A  diuretic 
mixture,  composed  of  infusion  of  digitalis,  acetate  of  potash, 
spirits  of  nitrous  ether  and  cinnamon  water,  is  one  of  the 
most-  active  diuretics  with  which  I  am  acquainted.  [We 
need  not  exceed  a  drop  an  hour  of  the  fluid  extract  of  digi- 
talis.] It  must  be  remembered  that  diuretics  produce  less 
effect  on  effusions  in  the  pericardium  than  on  cellular  infiltra- 
tions. 

H. 

Page  120,  ^  53.  "  Embolism  from  the  accidental  develop- 
ment of  the  coagulating  principle  of  the  blood."  The  coag- 
ulating 'principle  (which  is  globulin,  according  to  A.  Schmidt, 
who  demonstrated  it,  and  whose  experiments  have  been 
repeatedly  verified,)  is  never  developed  "  accidentally"  in 
point  of  fact,  but  is  often  left  undestroyed  by  accident,  and 
this  accident  is  doubtless  the  chief  cause  of  emholism.  Oldb 
ulin  is  a  principle  common  to  all  the  histologic  elements,  but 
it  is  an  integral  part  of  the  blood  globule  itself — hence  the 
superior  coagulating  energy  manifested  by  blood  globules. 
Blood  drawn  slowly,  coagulates  slowly,  because  the  lining  of 
the  blood-vessels  in  its  normal  state  has  the  power  of  neu- 
tralizing the  globulin,  else  the  blood  could  not  remain  fluid. 
It  may  be  stated,  then,  that  so  ^ong  as  the  blood  is  uncon- 


208  APPENDIX. 

taminated  with  any  substance  containing  free  globulin — as, 
for  example,  a  slired  of  lymph — and  so  long  as  the  walls  of 
the  vessels  are  in  their  normal  condition,  coagulation  of 
blood  in  the  vessels  will  not  take  place,  however,  slow  or 
frequently  interrupted  the  circulation  may  become,  whether 
from  the  action  of  veratria,  by  which  the  contractility  of  the 
heart  is  impaired,  or  from  the  action  of  digitalis,  or  potassium 
salts,  by  which  the  vagi  are  probably  irritated  and  the 
heart's  systoles  thus  retarded,  or  whether  from  incompetent 
mitral  valves,  by  which  a  systole  is  wasted,'as  to  its  effect  in 
propelling  the  blood  ;  none  of  these  cause  or  even  tend  to 
cause  coagulation  of  the  blood  without  the  presence  of  the 
coagulating  principle.  But  directly  a  blood-vessel  becomes 
diseased  in  any  one  spot,  say  from  inflammation  so  extensive 
as  to  cause  exudation  of  lymph  on  its  inner  coat,  on  that 
point,  we  have  a  coagulating  principle  present,  and  the  pro- 
duction of  minute  emboli  or  thrombi  begins.  So,  if  there  be 
calcarious  deposit  in  an  artery,  on  a  valve,  or  the  endocardium, 
and  the  deposit  be  not  covered  with  the  healthy  lining  of  the 
artery,  or  the  healthy  endocardium  at  that  point,  we  have  a 
present  negative  cause  of  coagulation  of  the  blood  before 
death — negative,  because  the  action  of  the  living  lining  of 
the  vessel  is  necessary  to  the  decomposition  of  the  globulin. 
So  uhenever,  from  any  cause,  a  portion,  small  or  large,  of 
surface  of  a  vessel,  or  of  the  heart  in  contact  vyith  the  blood,  has 
lost  its  vitality — that  moment  coagulation  may  begin  at  that 
point.  The  torrent  of  the  blood  may  prevent  the  formation 
of  emboli,  and  thus  secure  the  patient  from  harm.  Thus,  in 
the  living  organism,  fluidity  of  the  blood  is  maintained  by 
the  healthy  vascular  walls,  and  by  the  simple  physical  action 
of  the  decomposition  of  the  globulin,  or  its  transformation 
into  fibrinogen. 

I  have  objected  to  giving  sulphate  of  magnesia  (page  128, 
Jc,)  because  of  its  tendency  when  absorbed  to  induce  coagula- 


APPENDIX. 


tion  of  the  dissolved  fibrin  of  the  blood  ;  thus  it  should  favor 
the  production  of  thrombi  in  all  lax  conditions  of  the  system. 
Of  course  it  would  be  less  injurious  in  stlienic  than  in  asthenic 
inflammations  ;  it  is  less  likely  to  do  harm  in  large  than  in 
small  doses,  because  less  likely  to  be  absorbed. 

L 

The  following  tables  of  Bigot,  on  the  thickness  of  the 
walls  of  the  ventricles,  from  Walshe,  are  of  real  practical 
value.    The  measurements  are  in  French  lines. 


MALES. 

Left  Ventricle    - 

Septum 

Right  Ventricle 


Base, 
t  €8-122 
4  5-  12 
1  113-12! 


Middle.    I     Apex. 
5  19-122j3  95-122 

1  29-24411    2-  61 


rEMALES. 

Base. 

Middle. 

Apex. 

Left  Ventricle    - 

4    3-8 

4  4-5 

3  13-  30 

Septum       .... 

4  1-36 

Right  Ventricle 

1     2-3 

1  7-24 

.673-720 

"  The  mean  thickness  of  the  wall  of  the  right  auricle  has 
been  estimated  at  about  one  line  French  by  M.  BouUand, 
that  of  the  left  at  one  line  and  a  half." 

Valvular  diseases  are  dangerous  to  life,  and  cause  annoy- 
ance and  suffering  in  the  following  order : 
Tricuspid  incompetency. 
Mitral  constriction  and  incompetency. 
Incompetency  of  aortic  valves. 
Pulmonary  constriction. 
Aortic  constriction. 
Incompetency  of  pulmonary  orifice  and  constriction  of  the 
tricuspid  orifice,  are  so  infrequent,  and  so  little  known,  that 
they  cannot  be  estimated  as  to  their  effects. 

Valvular  diseases  are  not  generally  causes  of  sudden  death ; 
they  are  susceptible,  as  to  their  effects,  of  great  alleviation, 
and  perhaps  to  arrest  as  to  their  progress.  But  it  must  al- 
ways be  borne  in  mind  in  estimating  the  prognosis,  that  one 
of  them— aortic  incompetency — is  liable  to  kill  suddenly,  and 
without  any  marked  warning  of  imminent  danger. 


The  following  illustration  of  tbe  thoracic  regions  and  their  contents, 
copied  from  Walshe  on  the  Heart,  may  be  found  convenient. 

DiAQRAM,  exhibiting  the  relationship  of  the  heart  and  great  Teasels  to 
the  lungs,  (in  moderate  inspiration,)  and  to  the  regions  of  the  heart. 


1  to  10  inclusive,  ribs;  a  a  supra-clavicular  region;  6  6  clavicular; 
c  c  infra-clavicular;  d  d  mammary;  e,  t  infra- mammary;  /supra  sternal; 
g  upper  sternal  ;  h  lower  sternal;  i  i  integuments  turned  back;  ff 
nipples;  k  right  auricles;  I  right  ventricle;  m  left  auricle,  appendix 
almost  solely  seen;  n  left  ventricle;  o  pulmonary  artery;  p  arch  of 
aorta;  the  letter  g^  indicating  upper  sternal  region,  is  also  on  the 
aortic  arch,  transverse  portion;  p  (farther  to  the  right)  vena)  cavte  supe- 
rior; rr  innominate  veins;  s  innominate  artery;  tt  subclavian  veins. 
The  dotted  lines  indicate  the  outlines  of  the  thoracic  regions;  the  dark 
lines  the  edges  of  the  luugs.     The  heart  and  vessels  are  supposed  to  be 


^z^ 


INDEX 


Ao&TA,   disease  of  ralves   of,  179, 
194,  195,  48,  85. 

cause  of  sudden  death  in  dis- 
eases of  valves  of,    81,  22. 
Aortic  regurgitation,  172,  70. 

obstruction,  192,  62. 

incompetency,  54. 

valves,  location  of,  12. 

diastolic  murmurs,  106. 

orifice,  narrowing  of,  194. 

valves,  consequence  of  disease 
of,  192. 
Arteries,  vermicular  movement  of, 

64. 
Ammonia,  muriate  of,  47. 

and  lavander,  144,  124. 
Apex  of  heart,  10. 
Atiricles,  location  of,  see  diagram. 
Anatomical  facts,  10. 
Age,  old,  effects  on  nutrition,  18. 
Auriculo- ventricular  valves,  12, 13. 
Arterial  stimulants,  40,  45. 
Antimony,  42. 
Anemia,  pulse  in,  38. 

perchloride  of  iron  in,  43. 

precordial  uneasineai  in,  38. 

murmurs  in,  101. 
Anisurisni,  172,  180. 

treatment  of,  176. 

bruit  of,  175- 
Arcus  senilis,  154. 
Argo.  case  ot,  117. 
Angina  ptctoris,  38.  41,  163. 

pain  of,  neuralgic,  165. 

diagnosis  of,  164. 

treatment  of,  166. 

Walsh e  on,  168. 
Animal  diet,  144. 
Arsenic  pills,  162. 
Atelectasis,  11 '^. 
Alkaline  springs,  129. 
Alkulies,  121. 
Alcaohulio  9timulii8,  caution,  123. 


Asthenic  rheumatism,  123. 
Attrition  or  Friction  Murmur,  181. 

Blowing  Sound,  25. 

Bromide  of  Potassium,  154,  137 . 

Bright's  Disease,  106,   108,  128. 

Beef  tea,  184. 

Beef  juice,  185. 

Bleeding,  local,  185. 

in  anemia,  185. 
Blood,  non-oxygenated,  its  effect!, 
67. 

when  to  be  taken,  184. 
Brandy,  124. 
Blood  deterioration,  184. 
Blisters,  129. 

Coffee,  40. 

Causes  of  discrepancies  of  opinion, 

5-8. 
Courtezans,  15. 

Constriction  of  mitral  orifice,   95, 
88. 

aortic  orifice,  62. 
Chicken-breast,  100. 
Corvisart,  112,  91. 
Collin,  112. 
Coagulation,  not  induced  by  itasis, 

1-^8. 
Cardiac  atrophy,  133. 
Cold  sponge  baths,  144. 
Cyanosis,  177, 
Case  of  inorganic  murmur,  J"6. 

of  organic  murmur,  ^.S. 

of  general  disease  of  the  heart, 
45. 
Capillary  circulation,  50. 
Cod-liver  oil,  153.. 
Clots  in  the  heart,  163. 
Cups,  42. 

Carbonate  of  ammonia,  124. 
Cod-liver  oil,  170. 


INDEX. 


Daiton,  12 

Digitalis,  ]43. 

Digitalis,  antimony  and  iron,  42. 

argument  against  answered, 
60. 
Diagnosis  of  organic  disease  of  the 
heart,  24. 

tricuspid    regurgitation,  181. 

of  dilatation,   i8u. 

of  endocarditis,  181. 

of  pericarditis,  ]81. 

of  hypertrophy,  180. 

of  aneurism,  17  2,   180. 

of  mitral  constriction,  180. 

of  aortic  regurgitation,  179. 

of  roughness  or  constriction  of 
the  aortic  orifice,  179. 

of  inorganic  murmur,  i83. 

of  softening  of  the  heart,  182. 

of  fatty  degeneration,  132. 

of  angina  pectoris,  183. 

of  hypertrophy   of   left  ven- 
tricle, 135. 
Dropsy,  60. 

cardiac,  196. 

Appendix  C. 

of  the  extremities  a  measure 

of  valvular  disease,  51,  52. 

Differential  diagnosis  of  endocarditis 

and  pericarditis,  104. 
Dilatation,  diagnosis  of^  141. 

pulse  in,  142 

sexual  inclination,  142. 

treatment  of,  143. 

Piorry's  treatment  of,  145. 


General  rule  in  treatment  of  heart 

diseases,  187. 
Growths  heterologous,  16. 
Guffroy's  cod-liver  extract  in   ■oft- 

ening,  152. 

HxART,  form  and  location  of,  10. 

acute  disease  of,  14. 

forgetfulness,  53. 

oedema  of,  132. 
fiope,  90. 

Ilydro-pericardium,  132. 
Hypertrophy,    134,  193,   196. 

of  right  ventricle,  193. 
Hypertrophy  of  valves,  133. 

and  dilatation,  134,  196. 

diagnosis  of,  136. 

bromide  of  potassium  in,  137. 

treatment  of,  138. 

pulse  in,  136. 

caae  of,  140. 

with     fatty     metamorpboiii, 
134. 
Haemo-pericardium,  131. 

endocardium,  131. 
Heart's  cavities,  133. 

Introduction,  6. 

Inflammation  of  heart's  membranes, 

103. 
lodinized  injections  after 

pericardium,  132, 
Iodide  ol  potassium,  129. 


tapping 
129. 


Jot,  13. 

Jugular  pulse,  46. 


Erotic  passion,  15. 

Endocardial    Murmur,    significance  Latham,  26. 


of,  181. 

Endo-pericarditis,  acute  and  chro. 
nic,  131. 

Frimissement  Cataire,  89,  91. 
Friction  sound,  97. 
Fatty  degeneration,    diagnosis    of, 
153. 

case  of,  154. 

pulse  in,  155. 

difficulty  of  diagnosis  of,  160. 

treatment  of,  161. 

prognosis  in,  176. 
Fibrinous  clots,  196. 
First  sound,  11. 
Flint  Austin,  88. 

Gtllic  acid  in   Bright's  disease,  128. 


Laennec,  71. 
Life,  liow    destroyed  by  heart  dii- 
ease,  187. 

Murmurs  and  frictions  how  diatin- 
guished,  19,  20,  21. 
propagation  of,  22- 
from  roughened  valves,  24. 
organic  and  inorganic,  96. 
"come  and  go,"  98. 
diastolic  not  always  organic, 

101. 
regurgitant  aortic,  48,  24. 
mitral  diastolic,  or  direct,  48. 
in  disease  of  pulmonic  valves, 

84,  87. 
systolic  tricuspid,  114. 
Mitral  valve,  location  of,  12. 


Mitral   Valve,   diagnosis  of  incom- 
petency of,  32. 
diastolic  murmur  of,  88. 
constriction,  treatment  of,  95, 
Meckel's  case  of  narrowing  of  aorta, 

64. 
Markham,  114. 
Manganese,  sulphate  of,  126. 
Mitral    constriction,    consequences 
of,  190.       * 
mode  of  death  in,  192. 

Nitrate  of  potash,  127. 

(Edema  of  heart,  132. 

Order  of  frequency  of  affection    of 

heart's  cavities,  134. 
Opium,  128. 
Order  of  advent  of  cardiac  lesions, 

197. 
Obstructions  in  lungs,    effects    of, 
]34. 
of  tricuspid,  200. 

Pulse,  intermittent.  Si., 
see  Appendix  B. 
rhythmical  intermittence  of, 

37. 
jugular,  49. 
how  reduced,  61. 
depressibility  of,  84. 
Pulses,  visible,  64. 
Purgatives,   128. 

Praecordial  region,  how  found,  11. 
Permanent  disease    of    the    heart, 

whence  derived,  16. 
Pain,  52. 

Palpable  or  visible  thrill,  94. 
Pericarditis,  106. 

characteristic  sign  of,  107. 

treatment  of,  1 20, 

rheumatic,  1'22. 

alkalies  in,  ]24. 

sthenic  and  asthenic,  126. 

purgatives  in, 

and    endocarditis,    treatment 

of,   !28. 
tapping  in,  129. 
hypertrophy  from,  130. 
Propylamin,  121,  170. 

and  laudanum  in  rheumatism, 
Piorry's  diagnosis  and  treatment  of 
dilatation  and  hypertrophy, 
145. 
PrfiBCordial  region,  11. 
Principles  of  treatment  of  disease  of 
heart,  283. 


Prognosis  in  diseases  of  heart,  gen- 
eral reflections  on,  187. 
Perchloride  of  iron,  143. 

Rheumatism,  169. 

of  two  kinds,  169. 

sulphate  of  manganase  in,  171. 
Rokitansky  177. 

Regions  of  the  chest,  see  diagram. 
Region  praecordial,  11,  12. 
Rest  in  bed,  etc.,  44. 
Right  ventricle,  dilatation  of,  173. 

hypertrophy  of,  173. 
Rupture  of  heart,  158,  196. 

Morel  la  Vallee's  case,  169. 
Rules  of  diagnosis  of  disease  of  heart, 
179. 

Second  Sound,  13. 

how  produced,  25: 

where  heard,  12. 
Sounds,  how  propagated,  24. 
Sound  first,  how  caused,  12. 

Appendix  A. 
Systoles  retarded,  see  Appendix  B. 
Sign,  Dr.  Corrigan's,  54. 
Skoda,  on  mitral  constriction,  90. 
Sudden  death,   Mauriac's  cases  of, 
72-5. 

in  disease  of  heart,  mechanism 
of,  78. 
Sedative  impression  on   the  heart, 
how  it  should  be  made,  186. 
Softening  of  heart,  150. 

causes  of,  150. 

simple,  or  non -fatty,  157. 

Simple,  treatment  of,  162. 

simple,  prognosis  in,  153. 

fatty  diagnosis  of,  153. 

fatty,  case  of  154. 

pulse  in,  156,    161. 

case  of,  with  rupture,  168. 

first  sound  in.  161. 

treatment,  161. 

prognosis  in,  ]63. 

connection  with  rupture,  168, 

see  Appendix  F. 
Sulphate  of  manganese,  129. 

Tricuspid  constriction,  murmur  of, 

199, 
Taraxacum  and  calomel,  144. 

Valves,  location  of,  24. 
aortic,  12,   194. 
of  pulmonary  artery,  12. 
mitral  and  tricuspid,  13. 


INDEX. 


Valves,    differential     diagnosis     In j Talves,  tricaspld  incompetency  and 
disea'-e  of.  49.  i  constriction    of;    175,     178, 

of   pulmonary  artery,  disease!  199. 


of,  86. 

tricuspid,     temporarily     in- 
competent, 105. 

pulmonic,    second  sound  of, 

32. 


mitral  mode  of  death  in  dis- 
ease of,  Appendix  D. 
Veins,  valves  of,  193. 
Visible  impulse,  135 


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